Radiology Coding Alert

Know which clues in the physician’s notes point to pharmacologic stress testing.

Approximately one-fifth of hospitalized patients with a COVID-19 infection experience myocardial injury, one study found. With cardiac magnetic resonance imaging (MRI), radiologists can evaluate any damage in the infection’s early stages.

Read on to learn how to correctly code cardiac MRI procedures.

Learn How Providers Evaluate COVID-19 Myocardial Damage

Patients suffering from a COVID-19 infection may experience several symptoms, including shortness of breath, fever, persistent cough, and fatigue. However, the infection can also cause harm that’s not easily assessed with the naked eye. A 2020 JAMA Cardiology study found 20 percent of patients with a COVID-19 infection experienced myocardial injury (https://jamanetwork.com/journals/jamacardiology/article-abstract/2763524). Evidence of myocardial (heart muscle) injury can appear in the later hyperinflammatory stage, occurring mere days after the initial symptoms begin.

Cardiac MRI is different from traditional MRI in that the procedure provides a physiologic evaluation, meaning it relates to the heart’s function (Learn more about traditional MRI in “Dive Into Specifics to Properly Code MRIs” on page 4). Radiologists may use the procedure to examine the extent of damage, if any, the viral infection is causing to the patient.

Physicians may also use cardiac MRI to assess the velocity flow mapping of a patient. “Velocity flow mapping provides a display of the velocity [speed] of blood flow through the cardiovascular system, which provides an even better look at the patient’s cardiac function and anatomy,” says Robin Peterson, CPC, CPMA, Manager of Professional Fee Coding and Audit Services, Pinnacle Enterprise Risk Consulting Services in Centennial, Colorado.

Additionally, cardiac MRI is a noninvasive method to detect and rule out myocardial inflammation caused by a COVID-19 infection. The procedure allows radiologists to safely localize sites of inflammation, evaluate the severity of tissue damage, and determine myocardial edemas (swelling) and necrosis (cell death).

Get to Know the Cardiac MRI CPT^® Codes

Suppose a morbidly obese 65-year-old patient diagnosed with symptomatic COVID-19 is referred to your radiology practice for the evaluation of their myocardial function. The patient has a history of high blood pressure and is experiencing acute severe chest pain with dyspnea (difficulty breathing) and heart palpitations. Their primary care physician (PCP) orders cardiac MRI without contrast, a stress test, and velocity flow mapping to determine or rule out myocardial injury due to the patient’s COVID-19 infection. Due to their infection and physical condition, the patient is unable to take a physical cardiovascular stress test, so the PCP orders a pharmacologic stress test. After performing the procedures, the radiologist interprets the results and submits their findings to the patient’s PCP.

In the 2022 CPT^® code set, you’ll find the following cardiac MRI codes under the Heart subsection of the Radiology chapter:

• 75557 (Cardiac magnetic resonance imaging for morphology and function without contrast material)
• 75559 (…; with stress imaging)
• 75561 (Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences)
• 75563 (…; with stress imaging)
• +75565 (Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure))

For the scenario above, you’ll assign 75559 to report the cardiac MRI without contrast since the radiologist also performed a stress test. The descriptor for 75557 indicates a cardiac MRI examination without contrast, but the “with stress imaging” wording in 75559’s descriptor is the difference between the two codes.

You’ll also assign add-on code +75565 to the claim, as the radiologist performed velocity flow mapping during the visit.

In addition to 75559 and +75565, you also need to report the pharmacologic stress test. The PCP ordered a pharmacologic stress test for the patient to further evaluate their myocardial function, but how do you recognize that information in the physician’s documentation?

Code a Pharmacologic Stress Test Correctly

The two types of stress testing available include a physical cardiovascular stress test, usually involving treadmill or bicycle exercise, and a pharmacologic stress test. When a pharmacologic stress test is ordered, the patient may not be able to perform a physical stress test. In that case, the “provider will document the patient’s inability to exercise adequately for the stress portion of the test due to physical limitations,” Peterson says. When reporting a pharmacologic stress test, the physician may document the intravenous (IV) administration of specific agents, such as adenosine, dobutamine, regadenoson, or dipyridamole, which help create a stress response in the patient, so the physician can evaluate the heart’s function. During the pharmacologic stress test, the provider can measure the interval hemodynamics — or study how the blood flows and the physical structures in which it flows — just as if the patient was physically exercising.

CPT^® instructs you to report a stress testing code in addition to 75559 or 75563 (Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging). To do this, you’ll choose from the following CPT^® codes:

• 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report)
• 93016 (…; supervision only, without interpretation and report)
• 93017 (…; tracing only, without interpretation and report)
• 93018 (…; interpretation and report only)

In the scenario above, 93015 is the correct choice to report the pharmacologic stress test since the radiologist performed the procedure, interpreted the results, and reported their findings back to the patient’s PCP.

Coding tip: According to CPT^® instructions before the cardiac MRI codes, you should report only one procedure in the 75557-75563 series per session.

Understand Which Cardiac MRI-Related Codes Are Reported Separately

Knowing which procedures are included and which codes are reported separately is crucial to ensuring a foolproof claim. When coding cardiac MRI procedures, you don’t need to code 3D rendering or the administration of contrast, if applicable, as these components are included in the basic procedure.

On the other hand, you will need to code the pharmacological stress agent separately if your provider supplied it. “Be sure to look at the dosing to make sure you are capturing the correct reimbursement,” Peterson says.