Radiology Coding Alert

Identify SPECT with ease to cut down on denials
 
The National Correct Coding Initiative's latest edits put a halt to reporting cardiac blood pool imaging with SPECT - stumping coders who want to report 78465 with 78472's add-on code CPT 78496 for a gated first pass of the right ventricle. We've got your best bet for reimbursement when you perform a SPECT and right ventricle gated first pass together.

Edit Your SPECT Coding

As of April 1, you can no longer report 78472 (Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress [exercise and/or pharmacologic], wall motion study plus ejection fraction, with or without additional quantitative processing) when you 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).
 
NCCI Edits says these are mutually exclusive procedures that carry a modifier indicator status of "0," meaning you cannot use modifiers to separate them. And if you report both, Medicare will only reimburse you for the lesser-valued of the two procedures.

"This doesn't come as too much of a surprise," says Cynthia A. Swanson, RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb. Many local coverage determinations already say they typically won't cover cardiac blood pool codes and perfusion imaging codes on the same date of service.

The reason is "limitations of uptake, low-photon energy and redistribution," according to National Heritage Insurance Company's Northern California LCD.

Never Report Undocumented Procedures

You'll often see reports for 78465, a SPECT study checking to see how the coronary arteries are supplying blood to the myocardium (cardiac muscle responsible for the function of the four chambers of the heart), says Bart Outzen, RT, RT(N), CNMT, director of nuclear medicine at Cardiovascular Physicians PA in Greenville, Miss.

At the same session, the physician may perform the services described in +78496 (Cardiac blood pool imaging, gated equilibrium, single study, at rest with right ventricular ejection fraction by first pass technique [list separately in addition to code for primary procedure]).

Mistake: CPT says to use 78496 only in conjunction with 78472, so some coders report an unperformed 78472 to justify reporting 78496.
 
Disaster averted: If you see a report that seems to merit 78465 and 78496, steer clear of throwing in 78472 just for payment. If you report SPECT 78465 with 78472 when the physician doesn't document 78472, a denial for not following NCCI is the least of your worries - you could be facing fraud charges, assuming a pattern of erroneous coding can be attributed to purposeful miscoding with the intent to achieve payment for services not provided or documented.

Try this: Based on CPT and payer guidelines, if you can't find a code that describes the service performed, you must assign an unlisted-procedure code, Swanson says.

Example: You perform a myocardial perfusion with SPECT and a gated first pass of the left and right ventricles without multiple gated acquisition scan (MUGA).

Tip: Because CPT lists 78496 as an add-on to 78472, if you see evidence to report 78496, double-check the chart to see if you missed the chance to report 78472,  Swanson says.

The procedure for 78472 involves a nuclear medicine camera taking images, which are timed to the cardiac cycle by ECG. This synchronization produces a display of cardiac wall motion.

Once you're sure you can't legitimately report 78472, use 78465 for the myocardial perfusion with SPECT and 78499 (Unlisted cardiovascular procedure, diagnostic nuclear medicine) for the gated first pass of the left and right ventricles. Whenever you report an unlisted-procedure code, you need to supply enough information to be sure the claims reviewer understands the procedure performed and its value.

Good news: You should typically compare an unlisted procedure to a listed procedure to give an estimate of the service's worth, Swanson says. In this case, you can explain that this is the service described in 78496, which typically brings in about $275, depending on your geographic area. You can check out the fee schedule at www.cms.hhs.gov/physicians/mpfsapp/step0.asp.

Acquaint Yourself With First Pass Studies

For first pass studies (for example, 78483, Cardiac blood pool imaging [planar], first pass technique; multiple studies, at rest and with stress [exercise and/or pharmacologic], wall motion study plus ejection fraction, with or without quantification) a technician injects a radiopharmaceutical into a patient's vein while the patient is in front of a specialized camera. The camera visualizes the bolus of radiopharmaceutical as it passes from the patient's venous system through the heart and lungs. The technician performs this imaging as the agent makes its "first pass" through the heart.

When a technician does the initial injection for a first pass study, the patient is already positioned in front of the camera (usually in left anterior oblique projection).
 
The technician watches the nuclear tracer flow through the right and left portions of the heart. The injection time and image acquisition time are simultaneous. This is recorded with images taken half second per frame for 64 frames. "In other words, this is one very, very quick procedure with one set of pictures,"  Outzen says.

EF note: Generally, you'll report ejection fraction (+78480, Myocardial perfusion study with ejection fraction [list separately in addition to code for primary procedure]) and wall motion (+78478, Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]) with a SPECT study but not with a first pass study. For the latter, you're primarily looking at the wall motion and the ejection fraction, so you wouldn't report these add-on codes in addition to the appropriate procedure codes.