Cardiology Coding Alert

Spot the SPECT service, and bring in an extra $193. January 2010 brought a double whammy for myocardial perfusion imaging: new codes and slashed reimbursement. You can help your practice stay in the black by mastering accurate use of the new codes. Start here: Myocardial perfusion imaging (MPI) allows the cardiologist to view the distribution of blood (perfusion) to the myocardial tissue (the heart wall's middle muscular layer). Cardiologists often perform multiple studies (at rest and under stress) for comparison purposes. Below are the 2010 codes that describe multiple-study MPI: CPT 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 78454 -- Myocardial perfusion imaging, planar (including 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 Keep in mind: These codes are specific to multiple studies. For information on single-study codes, see the last section. Separate SPECT From Planar for MPI Success The only difference between the two code definitions is that 78452 specifies "tomographic (SPECT) (including attenuation correction ...)" and 78454 states "planar". So the distinction is the type of imaging and the type of camera used. "In simple terms, the SPECT camera has the ability to rotate around the body during the imaging process, whereas the planar camera is stagnant during the imaging process," says Anne C. Karl, RHIA, CCS-P, CPC, CCC, coding and compliance specialist at St. Paul Heart Clinic in Minnesota. 2D vs. 3D: "In planar imaging (78454) the results are two-dimensional. SPECT (78452) produces three-dimensional images," says Debby Simmons, CPC, coder with Cumberland Cardiovascular Associates in Maryland. Remembering that SPECT stands for "single photon emission computed tomography" may help because computed tomography (CT) involves imaging in slices to produce three-dimensional views of the heart. Attenuation correction: Unlike 78454, 78452's definition includes "attenuation correction," which is a correction applied to SPECT imaging for photon absorption and scattering. Without the correction, deep structures will appear to have less tracer concentration than they truly do. So this difference in the code definitions again relates back to the imaging type. Expect SPECT Code for Most Claims Simmons notes that her practices use the rotating gamma camera far more often than the planar. "Planar technique is rarely done due to the advances in technology which SPECT imaging provides," Karl adds. In fact, "SPECT imaging is presently considered state-of-the-art for myocardial perfusion imaging," states the American Society of Nuclear Cardiology Imaging Guideline for Myocardial Perfusion Planar Imaging (www.asnc.org/imageuploads/ImagingGuidelinesPlanar021109.pdf). But don't count out planar imaging (78454) entirely. The ASNC guideline states planar imaging may be best in the following situations:

• Bedside imaging for acutely ill or instrumented patients
• Quickly repeating views if the patient moves during acquisition
• Imaging obese patients who are too heavy for the SPECT table
• Imaging severely claustrophobic patients.

Caution: "Unfortunately, the terminology of SPECT vs. planar is often not documented in the formal stress test reports," says Karl. But the term "tomographic" is a solid indicator that the SPECT code is correct. For example, you may see documentation such as "gated emission tomographic reconstruction" for SPECT MPI. If you aren't sure, check "with your nuclear department, and inquire on the method they are using," Karl says. Payoff: Identifying the proper method does have benefits. As this chart shows, global 78452 ($379.97) pays nearly $193 more than global 78454 ($186.56): Aside from the SPECT/planar difference, the 78452 and 78454 code definitions are the same, stating they include "qualitative or quantitative wall motion, ejection fraction by first pass or gated technique additional quantification, when performed." Crucial: Heed the last two words --"when performed" -- which indicate the codes are appropriate whether the cardiologist performs those services or not, says Cynthia A. Swanson, RN, CPC, CEMC, CHC, senior manager, healthcare consulting, at Seim Johnson in Omaha, Neb. And if the cardiologist does perform those services, you should not code them separately. This is a major change from 2009, when you would have reported those services with codes such as the now deleted +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study... ) and +78480 (Myocardial perfusion study with ejection fraction...). Opportunity: Although 78452 and 78454 do include many services, you should continue to report the stress test (93015-93018, Cardiovascular stress test...), the stress-inducing agent (such as adenosine, J0152, Injection, adenosine for diagnostic use, 30 mg), and radiopharmaceuticals (such as A9500, Technetium, Tc-99m sestamibi, diagnostic, per study dose) if you provide them. As stated earlier, 78452 and 78454 are specific to multiple-study MPI. CPT also provides single-study codes: SPECT: 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) Planar: 78453 -- Myocardial perfusion imaging, planar (including 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) So if the cardiologist performs and documents only a single study, such as at rest only, you should report 78451 or 78453 rather than 78452 or 78454.