Medical necessity is an increasingly recognised issue. Documentation is key.
Coding for Single Photon Emission Computed Tomography (SPECT) cardiac imaging isn’t easy. You can justify the test only if your provider has a sound reason for the conduct of the procedure and has sequenced it well with other investigations.
What is SPECT? When your provider does a SPECT, he/she is essentially trying to measure the concentration of nucleotides that are introduced in the patient’s body.
When is a SPECT useful? Your physician may perform a SPECT for the diagnosis of the following clinical conditions:
Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Washington, helps to explain the CMS National Coverage Determinations (NCDs) 220.12, SPECT. Here is expert advice and guidance for myocardial SPECT. You can review the SPECT codes for myocardial imaging in table 1.
What is relevant in the SPECT NCD? Language in National Coverage Determination (NCD) 220.12 regarding “myocardial SPECT is very limiting with regard to coverage,” Bucknam says.
The NCD states SPECT is useful to “analyze blood flow to an organ, as in the case of myocardial viability” and to “differentiate ischemic heart disease from dilated cardiomyopathy,” Bucknam says, quoting the NCD.
“Make sure that documentation supports one of these reasons as the medical necessity for the test and that any other testing (e.g., EKG or echocardiogram) prior to the SPECT test supports that medical necessity,” Bucknam says.
You can read more about the CMS NCD 220.12 SPECT at: >https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=271&ncdver=1&DocID=220.12&bc=gAAAAAgAAAAAAA== & Check what the NCD language implies: Under the Indications and Limitations of Coverage section, the NCD states, “In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET performed to evaluate myocardial viability.”
A clear and quick analysis: In simple terms, the NCD implies that if the patient requires testing for myocardial viability, then the sequencing of testing matters for coverage.
Make note of this sequence: According to the NCD to test for myocardial viability, the sequence of testing that is acceptable includes the situation when the patient has an inconclusive SPECT and then undergoes an FDG PET.
However, it is not acceptable for Medicare if the patient has an inconclusive FDG PET and then is subjected to a SPECT.
Make sure you are meeting medical necessity requirements: “The big reason for denials that I have seen is medical necessity. There seems to be a trend toward ordering these SPECT tests instead of standard stress tests, and Medicare will not pay for that,” Bucknam explains.
To prepare your tip sheet, check your MAC’s Local Coverage Determination (LCD) for covered diagnoses and coverage rules, and watch for any advice the MAC has posted regarding their own SPECT audits. Keep in mind that in addition to medical necessity, you’ve got to meet the usual requirements like “a signed and dated order and a full report with interpretation, signed and dated as well,” Bucknam says.
For instance: Noridian performed a widespread review of 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) in southern California.
The error rate found was 74.17 percent. In the review findings posted online, Noridian provides a link to its LCD related to 78452 and provides a documentation guide to help with ensuring the medical record has what it needs.
You can see Noridian’s review findings at: https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/notifications-findings/myocardial-perfusion-imaging-tomographic-spect-78452-southern-ca-widespread-service-specific-probe-review-findings.
