Radiology Coding Alert

You can prepare for complicated nuclear medicine claims by challenging yourself with this real-life example. Read the report, and decide which codes you would submit before you go any further. Then check your answers against our experts'.

Procedure: Rest/stress myocardial perfusion SPECT study with gated wall motion analysis and calculation of the ejection fraction

Indication: Preoperative evaluation

Technique: A two-day protocol was used. Millicuries of Tc99m sestamibi was injected for rest images and millicuries Tc99m sestamibi was injected at peak exercise.

The patient exercised for 10 minutes of the Bruce protocol achieving 86 percent of the maximum predicted heart rate, stopping due to fatigue. No diagnostic electrocardiographic changes were seen. During the test, patient experienced no abnormal symptoms.

Scintigraphic findings: Homogeneous uptake of the radioisotope is seen throughout the myocardium.

The summed stress score is 0, the summed difference score is 0, and the TID ratio is normal.

Gated wall motion analysis shows normal wall motion and thickening. LV volume is normal. The calculated left ventricular ejection fraction is greater than 70 percent.

Impression: Normal rest/stress myocardial perfusion SPECT study.

This sample report documents a myocardial perfusion SPECT study at rest and stress, with gated wall motion analysis and ejection fraction calculation.

You should report 78465 (Myocardial perfusion imaging; tomographic [SPECT], multiple studies [including attenuation correction when performed], at rest and/or stress [exercise and/or pharmacologic] and redistribution and/or rest injection, with or without quantification) for the tomographic (SPECT) myocardial perfusion imaging study, says independent coding consultant and instructor Linda Templeton, CCS-P, CPC, CPC-H, who also codes nuclear medicine procedures for a large teaching hospital in southeast Michigan.

Don't miss: You may report +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study) and +78480 (Myocardial perfusion study with ejection fraction) separately for the wall motion and ejection fraction (EF), says Cheryl Klarkowski, RHIT, CPC, coding specialist with Baycare Health Systems in Wisconsin.

Codes 78478 and 78480 represent services separate and distinct from 78465, Templeton says, citing the AMA's October 2004 CPT Assistant.

And forgetting to include these codes means you're letting roughly $40 go down the drain for professional services, according to national payment rates listed on the Medicare physician fee schedule, online at http://www.cms.hhs.gov/pfslookup.

Modifier tip: Remember to append modifier 26 (Professional component) if you're only reporting the professional services, Templeton says.

If you typically shudder when you have to choose an ICD-9 code for a "normal" study, you're in luck with this pre-op evaluation.

Code V72.81 (Preoperative cardiovascular examination) is a Medicare payable diagnosis, and most insurance companies will accept it, Klarkowski says.

Tip: If the physician did document findings in the impression, you should report that diagnosis in addition to V72.81, Templeton says.

Medicare issued guidelines for coding pre-op exams in 2001 and published them in the old Medicare Carriers Manual, Part 3, Section 15048, online at (http://www.cms.hhs.gov/transmittals/downloads/R1719B3.pdf). Report the pre-op V code first, followed by the surgical diagnosis, followed by the code for any significant findings or other relevant conditions.

The facility that incurs the cost of the imaging agent reports the agent, Templeton says. So if you're reporting a physician's services and the hospital provides the agent, you should not report a HCPCS code for the agent.

But if you are responsible for reporting the agent, this report presents a problem because the provider didn't document the amount of Tc99m sestamibi used. HCPCS lists this agent (Cardiolite) under A9500 (Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries). Because the descriptor includes an amount -- "per study dose, up to 40 millicuries" -- you need to know the amount used to report units accurately.

You should ask the provider to amend the report to reflect the accurate amount, Templeton says. "Verbal instruction is not enough" because documentation must support the codes and units you report, she says.

Coding roundup: For this case study, you should report the following:

• 78465 (with modifier 26 if reporting professional service only)

• 78478 (with modifier 26 if reporting professional service only)

• 78480 (with modifier 26 if reporting professional service only)

• A9500 (if you bear the cost of the agent)

• V72.81.

Resource: Learn more about SPECT at the "Get the Inside Scoop on Nuclear Medicine Revisions and Maximize Your Practice's Revenue" seminar offered at The Coding Institute's 2008 Radiology Coding & Reimbursement Conference, April 13-15, in Denver (http://www.codingconferences.com/radiology08a.htm).