Cardiovascular Nuclear Medicine Claims Under the Microscope

Cardiovascular Nuclear Medicine Claims Under the Microscope

Physicians and non-physician practitioners: You are potentially submitting claims for cardiovascular nuclear medicine procedure codes with ICD-9-CM codes that do not support medical necessity for these services.

Says who? A recovery auditor for the Centers for Medicare & Medicaid Services (CMS) that recently conducted automated reviews of such claims.

Cardiovascular and Thoracic Surgery – CCVTC

CMS encourages physicians to review the diagnosis codes that support medical necessity for cardiovascular nuclear medicine procedures, such as 78451 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); single study, at rest or stress (exercise or pharmacologic). A comprehensive list of diagnosis codes is included in each Medicare administrative contractor’s (MAC) local coverage determination (LCD) for cardiovascular nuclear medicine. Locate your MAC’s LCD for cardiovascular nuclear medicine on the Medicare Coverage Database website.

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Be sure to check your MAC’s utilization guidelines. National Government Services, Inc.’s LCD for Cardiovascular Nuclear Medicine (L26859) states:
Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years would be reimbursable; otherwise tests repeated in the absence of changes in cardiac signs or symptoms will be considered not medically necessary.Adenosine may be reported with an NOS no greater than that required to bill an amount administered at 140 mcg/kg/min for 6 minutes. Higher dosages of this biological will be considered medically unnecessary.
Source: CMS MLN Medicare Quarterly Provider Compliance Newsletter, Guidance to Address Billing Errors, vol. 5, issue 3, April 2015
Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 425 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

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