Cardiology Coding Alert

CPT® Skills:

Familiarize Yourself With These 78492 Facts to Avoid Denials

Hint: Always report the appropriate radiopharmaceutical diagnostic agent tracer.

Reporting Positron Emission Tomography (PET) scans can be tricky because there are so many coverage rules and stipulations to remember. But, you don't have to make the same mistakes other practices have made regarding these codes.

Check out the valuable insight Jean-Pierre Dalhouse, education outreach representative at Noridian Healthcare Solutions in Fargo, North Dakota, shared in a recent webinar about cardiology code 78492 (Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress).

What are PET Scans? Find Out

A PET scan is a minimally invasive diagnostic imaging procedure that assesses the perfusion and level of metabolic activity in various organ systems of a patient's body, Dalhouse defines.

Covered or not: A PET scan is only covered in clinical situations where the results may help avoid an invasive diagnostic procedure or when the results may help the cardiologist choose the best anatomical location to perform an invasive diagnostic procedure, Dalhouse says.

However, a PET scan is not covered for other diagnostic uses. It's also not covered for screenings - testing patients without specific signs and symptoms of disease, Dalhouse adds.

Discover Coverage Requirements for 78492

A cardiologist performs a 78492 procedure to detect the physiologically significant narrowing of the patient's coronary artery.

"The results of the [78492] test should lead toward risk factor modification to delay or reverse the progression of atherosclerosis, alleviate symptoms of ischemia, and improve patient survival by either medical therapy or revascularization procedures such as bypass surgery or percutaneous coronary intervention," Dalhouse says.

According to the Medicare National Coverage Determinations Manual in Chapter 1, Part 4, section 220.6.1, a PET scan will be covered if the cardiologist performs it at rest or with pharmacological stress for noninvasive imaging of the perfusion of the heart to diagnosis and manage patients who have known or suspected coronary artery disease (CAD), if the following requirements are met:

  • The cardiologist performs the PET scan, whether at rest alone, or rest with stress, in place of, but not in addition to, a single photon emission computed tomography (SPECT); or
  • The cardiologist performs the PET scan, whether at rest alone or rest with stress, following an inconclusive SPECT. If this is the case, the PET scan must have been considered necessary to determine what medical or surgical intervention is required for the cardiologist to treat the patient. The manual defines an inconclusive test as a one "whose results are equivocal, technically uninterpretable, or discordant with a patient's other clinical data and must be documented in the beneficiary's file."

ICD-10 codes: To learn which diagnosis codes support the medical necessity for 78492, you should look at your local coverage determination (LCD). For example, Noridian's LCDs for PET scan coverage are A54666 for Jurisdiction E (JE) and A54668 for Jurisdiction F (JF).

Don't miss: Any use of PET scans that are not specifically listed in the NCD are non-covered, according to Dalhouse. So, providers are encouraged to review the entire CMS NCD for PET scans.

Physicians should bill G0235 (PET imaging, any site, not otherwise specified) for non-covered indications, Dalhouse adds.

Don't Forget to Report the Radiopharmaceutical Diagnostic Agent Tracer

You should always report the applicable radiopharmaceutical diagnostic agent tracer when billing for a PET scan service, Dalhouse says. Applicable tracer codes for PET scans include the following:

  • A9526 (Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries)
  • A9555 (Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries)
  • A9580 (Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries)
  • Q9982 (Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries)
  • Q9983 (Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries).

Caution: A4641 (Radiopharmaceutical, diagnostic, not otherwise classified) is not an applicable tracer for PET scans.

Keep These Questions in Mind When Billing 78492

Medical Review shared the following helpful thoughts you should remember when reporting 78492, according to Dalhouse.

  • You should include a detailed explanation for why you performed the PET. Ask yourself: Why did you perform the PET instead of another test? What are you looking for that only that PET will tell you? And, remember, "using the reason that the patient can't walk on a treadmill is not a sufficient explanation," Dalhouse says. "We need more of a description as to why."
  • If the cardiologist performs another test first, he should complete and read the test results before performing a PET. "You should not order an echo and a PET at the same time, if you're assessing myocardial ischemia," Dalhouse cautions.
  • Low-risk surgery usually does not require a PET.