Radiology Coding Alert

A field trip to the nuclear department will take your coding up a notch.

CPT rang in 2010 with brand new, all-in-one codes for myocardial perfusion imaging, packing in wall motion, ejection fraction, and more. Now that the codes have been in place a few months, the time is right to check in and make sure you've mastered the subtleties between your SPECT and planar options.

Start here: Myocardial perfusion imaging (MPI) allows the nuclear medicine physician to view the distribution of blood (perfusion) to the myocardial tissue (the heart wall's middle muscular layer). Physicians often order multiple studies (at rest and under stress) for comparison purposes. Below are the 2010 codes that describe multiple-study MPI:

• CPT 78452 -- Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
• 78454 -- Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.

Keep in mind: The above codes are specific to multiple studies. For information on single-study codes, see Part 2 in the next issue.

Spy the SPECT/Planar Difference

The only difference between the two code definitions is that 78452 specifies "tomographic (SPECT) (including attenuation correction ...)" and 78454 states "planar." The distinction is the type of imaging camera used. Simply put, the SPECT camera detector "has the ability to rotate around the body during the imaging process," whereas the planar camera detector is stationary during the imaging process, says Anne C. Karl, RHIA, CCS-P, CPC, CCC, coding and compliance specialist at St. Paul Heart Clinic in Minnesota.

2D vs. 3D: "In planar imaging (78454) the results are twodimensional," says Debby Simmons, CPC, coder with Cumberland Cardiovascular Associates in Maryland. When you look at a 2D image, the patient's left is on the left and the top is on the top, says Bruce W. Hammond, CRA, CAAMA, CNMT, executive vice president of Diagnostic Health Services, which serves more than a dozen states.

On the other hand, "SPECT (78452) produces threedimensional images," says Simmons.

The 3D SPECT images show a cross-section format with the imaged organ's front on the top of the image and the back on the bottom, like bread slices, Hammond explains. (Check out this image posted on Wikimedia Commons: http://commons.wikimedia.org/wiki/File:Heart_spect_imaging.jpg.) Remembering that SPECT stands for "single photon emission computed tomography" may help because computed tomography (CT) involves imaging in slices to produce threedimensional views of the heart.

Attenuation correction: Unlike 78454, 78452's definition includes "attenuation correction," which is a correction applied to SPECT imaging for photon absorption and scattering. Without the correction, deep structures will appear to have less tracer concentration than they truly do. So this difference in the code definitions again relates back to the imaging type. High-Tech SPECT Is More Common Simmons notes that her practices use the rotating gamma camera far more often than the planar. "Planar technique is rarely done due to the advances in technology, which SPECT imaging provides," Karl adds. In fact, "for most applications, SPECT should be performed," states the American College of Radiology "Practice Guideline for the Performance of Cardiac Scintigraphy" (www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/nuc_med/cardiac_scintigraphy.aspx).

But don't count out planar imaging (78454) entirely. The ACR guideline states that "planar imaging may be performed when the patient is unable to undergo SPECT (e.g., extreme obesity, claustrophobia, or inability to lie recumbent or remain immobile)."

Caution: Don't assume the above cases involve planar imaging. The staff may use a portable gamma camera at the bedside, for example. So check your documentation. Ace Terms to Match Codes to Report "Unfortunately, the terminology of SPECT vs. planar is often not documented in the formal stress test reports," says Karl.

But the term "tomographic" is a solid indicator that the SPECT code is correct. For example, you may see documentation such as "gated emission tomographic reconstruction" for SPECT MPI. If you aren't sure, check "with your nuclear department, and inquire on the method they are using," Karl says.

Term tips: Other terms you may see that indicate SPECT imaging include the following, Hammond notes:

• horizontal long axis
• short axis
• transverse
• sagittal
• reconstruction.

Hammond adds that the following terms are indicators of

• planar imaging:
• anterior
• posterior
• oblique.

Similarly, "slices" or references to second views obtained by a given number of projections (usually 64), point to SPECT as  well, Hammond notes.

Best bet: "Visit the nuclear medicine department," Hammond advises. Watch a patient have the test or at least speak with the staff to gain a better understanding of the test, he says."Forge a relationship where you can easily explain to them, in a mutual learning environment, what documentation you need to have so their studies are billed and paid appropriately." Good communication reduces costs and boosts your clean claim percentages, Hammond adds. "You work hard to bill and code correctly, and they work hard to get the best images for interpretation. You are both on the same team and the procedure is not complete until the bill is paid -- forge a mutually beneficial, supportive relationship with the patient at the center of the discussions."

Stay tuned: Next month, dig even deeper into these nuclear medicine codes with information on documentation do's, which codes you should and shouldn't report on the same claim, and which codes to report for single studies.