Cardiology Coding Alert

Are you reporting all the nuclear medicine services your cardiologist is performing? If not, you could be jeopardizing the extra revenue your practice needs.

Read through this nuclear medicine note, and determine all the codes you should report. Then compare them with our experts' recommendations.

Impression: Normal examination.

Clinical indication: Chest pain.

Test: The patient exercised for 8 minutes 52 seconds and reached a maximum heart rate of 152 beats per minute or 86 percent of the maximum predicted for age. I gave the patient 30 millicuries of technetium-99m-labeled sestamibi at peak heart rate. I obtained tomographic images of the heart 30 minutes later. I performed a gated study, and I calculated the left ejection fraction. I generated the report after I reviewed both the attenuation and the non-attenuation corrected images.

SPECT perfusion: There is uniform tracer distribution throughout the left ventricle and no focal abnormality.

Gated images: Left ventricular cavity size is normal. There is normal regional wall motion and thickening.

LVEF: Left ventricular ejection fraction is calculated to measure approximately 65 percent.

According to Tammy Judd, hospital coordinator at Spokane Cardiology in Washington, when you read the test notes, you should have isolated the following key phrases:

• "I obtained tomographic images of the heart 30 minutes later." This tells you the SPECT code.

• "I performed a gated study." This tells you the left ventricle (LV) code.

• "I calculated the ejection fraction." This tells you the ejection fraction (EF) code.

SPECT: First, you should report the myocardial perfusion imaging code 78464 (Myocardial perfusion imaging; tomographic [SPECT], single study [including attenuation correction when performed], at rest or stress [exercise and/or pharmacologic], with or without quantification) for "single study."

LV: You should report +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]) because the cardiologist evaluated the function of the left ventricle. Code 78478 represents the actual assessment of watching the ventricle contract and relax.

EF: The cardiologist also evaluated ejection fraction, which is the number that's generated from the wall motion study. For this service, you should report +78480 (Myocardial perfusion study with ejection fraction [list separately in addition to code for primary procedure]).

Red flag: You cannot bill 78478 unless the physician assesses the wall motion, nor can you bill 78480 unless the doctor assesses the ejection fraction, says Cheryl Klarkowski, RHIT, coding specialist with Baycare Health Systems in Green Bay, Wis. Make certain your cardiologist's documentation includes these evaluations.

Remember, if your cardiologist performs these three radiologic services in the hospital, you should append modifier 26 (Professional component) to each code (78464, 78478 and 78480), Judd says.

Stress test: For the stress test portion, you should report a code from the 93015-93018 series, depending on the setting.

For example, you would report 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) if your physician administers a cardiovascular stress test in the office, providing the procedure's technical component (that is, the physician's practice owns the equipment, employs the staff, pays the rent, pays the utilities, etc.) in addition to the supervision, interpretation and report.

But if your physician uses the hospital's equipment to perform a cardiac stress test and supervises the stress test and provides a written interpretation and report, you would report 93016 (... physician supervision only, without interpretation and report) for the physician supervision. To code the written interpretation and report, you should also use 93018 (... interpretation and report only). Pay attention to these codes' descriptors, which include key phrases such as "without interpretation and report" and "interpretation and report only."

In conclusion, your claim should look like this:

• 78464 (add modifier 26 if performed in the hospital)

• 78478 (add modifier 26 if performed in the hospital)

• 78480 (add modifier 26 if performed in the hospital)

• 93015-93018 (depending on the setting).

For the diagnosis code, you should report 786.50 to represent the patient's chest pain.

For the supply codes, if your cardiologist performs these services in the office, you should report A9500 (Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries). Typically you'll report two doses of A9500 with tests that include resting and stress imaging (the service described by 78465, ... 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) but only one dose of A9500 for tests that include only one imaging protocol (rest or stress), as in this case study.

-- Stacy Gregory, RCC, CPC, charge capture and reconciliation specialist for Franciscan Health Systems' Imaging Support Services in Tacoma, Wash., provided this example during her "Hot Topics in Nuclear Medicine" presentation at The Coding Institute's National Cardiology & Radiology Coding and Reimbursement Conference.

Look for information about 2008's cardiology conference at http://www.codingconferences.com.