Cardiology Coding Alert

When multi-uptake gated acquisition (MUGA) scans are performed to measure various aspects of the hearts wall motion, coders may be confused not only by the different codes associated with the test, but also by the other procedures often performed at the same time as the scans. To optimize ethical reimbursement, they need to ensure that all the codes applicable to the test, and not just the test itself, have been billed.

These scans, which often are performed in conjunction with a single-photon emission computed tomography (SPECT) scan, measure the motion of the ventricular walls to help cardiologists determine if there is any damage there, says Ray Cathey, PA, MHA, an independent coding specialist in Stockton, Calif. The images are then fed into a computer to measure the actual heart wall movement. MUGAs also determine the ventricle walls ejection fraction, i.e., how much of the blood in the heart gets pumped, in percentage terms. The higher the number, the better the heart is working.

CPT lists six codes that may apply to the two types of MUGA scans:

78472cardiac 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

78473multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification

78481cardiac blood pool imaging, (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction; with or without quantification

78483multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study ejection fraction, with or without quantification

78494cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing

78496cardiac 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)

Choosing among these codes, which can be confusing in itself, is only one part of the process. Because MUGA tests typically are not performed on their own but are done on patients in a variety of situations, other procedures also may be performed and should be billed in conjunction with the MUGA scan.

Understanding Gated Acquisition Tests

During these tests, which also may be referred to as wall motion studies or radionuclide ventriculograms, the patient receives an intravenous injection of an isotope that tags red blood cells, which allows multiple images of the heart to be synchronized to an electrocardiogram (ECG) (i.e., ECG-gated). The images are then entered into a computer, which provides cine display of cardiac chamber wall motion and calculates ventricular ejection fractions.

Coding will vary depending on whether the study is performed with the patient at rest or with supine or upright exercise or with pharmacologic stress (e.g., dobutamine). If the patient is tested once while at rest, the correct code would be 78472.

Note: Although the CPT descriptor indicates the single test may be performed on patients either at rest or stressed, in most cases, the single procedure is performed on resting patients.

Gated acquisition MUGA scans typically are planar, which means the images the camera receives are two-dimensional. If the cardiologist performs a circumferential, or three-dimensional, SPECT MUGA while the patient is at rest, 78494 should be billed.

Because useful data can be obtained by testing a patient during exercise (or for those patients who cant exercise, pharmacologic stress through the use of drugs such as dobutamine), MUGA scans usually are performed on patients both at rest and during exercise.

To do so, the patient also undergoes a stress test and is monitored both at rest and at various levels of exercise. The test itself is coded 78473. According to a medical policy bulletin from Xact Medical Services, the Medicare carrier in Pennsylvania, When myocardial perfusion (SPECT) and cardiac blood pool imaging studies are performed during exercise and/or pharmacological stress, the appropriate stress testing code should be paid in addition to ... 78472, 78473, 78481 and 78483. The codes for the stress testing are 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); 93016 (physician supervision only, without interpretation and report); and 93018 (interpretation and report only).

If two consecutive cardiovascular stress studies are billed on the same day in conjunction with exercise and resting nuclear studies, however, only one of the stress studies will be paid, according to the Xact bulletin.

Another local Medicare carrier, Louisiana Medicare Part B, states in a policy bulletin that MUGA scan codes, whether gated acquisition or first pass, are not to be used with any of the perfusion codes, quantitative or qualitative, even though nuclear medicine experts maintain that the application of single-photon emission tomography (SPECT) techniques may contribute significantly to the diagnostic accuracy of this imaging study.

That means that if a SPECT scan (78465, tomographic [SPECT], multiple studies, at rest and/or stress [exercise and/or pharmacologic] and redistribution and/or rest injection, with or without quantification) also is performed, which often is the case, only the SPECT may be billed.

Note: As mentioned previously, code 78494 may be used for an at-rest, ECG-gated study using SPECT.

Cathey adds that the single study (78472) and multiple study (78473) cannot be billed together, even if they are performed on different days. Its a little different with nuclear medicine, Cathey says. Because you compare one test to the other, whether they were done on the same day or different days makes no difference. You have to bill either/or, and if you performed more than one test, you have to bill 78473. If you try to bill 78472 and 78473 together, you are unbundling.

Cardiologists also should remember that MUGA results must be reported separately, Cathey says. Although a separate sheet of paper is not required, the MUGA report should be separated from the rest of the procedure notes by its own heading and should be clearly identifiable.

First Pass Tests

Gated acquisition tests as described above are excellent tools for measuring left ventricle wall function. If the cardiologist wants to examine the patients right ventricle, however, another test, known as a first pass test, will be performed. Cardiologists also use this test on cardiac patients with severe arrhythmia, for whom an ECG-gated test is contraindicated.

Another advantage of the first pass test is that it is a much quicker procedure30 minutes, as opposed to the 60 minutes or more required for the gated acquisition MUGA.

In first pass studies, the isotope, which is not attached to any cells, goes through the heart in a couple of beats. Consequently, a special camera is needed that can read a huge number of isotope counts in a very short time. As with the ECG-gated scans, the recorded images are planar.

Code 78481 is used for a single (usually at rest) study, whereas 78483 is used for multiple studies with the patient both at rest and during exercise (or pharmacologic stress).

In 1999, CPT introduced a new add-on code, 78496, that should be used to report the additional study of right ventricular function by first pass technique in addition to an ECG-gated scan. This code should be used only in conjunction with 78472, the single study ECG-gated scan typically performed at rest.

Pharmacological Agents and Supplies

If the patient cannot perform an adequate level of exercise, stress in the patients heart may be induced using drugs such as dobutamine (J1250) or dipyridamole (J1245). Medicare will pay for the drug separately from the test itself. Documentation in the patients progress notes, however, must show the medical necessity to justify the use of pharmacologic stress agents, according to the Louisiana Medicare policy bulletin.

Medicare also will pay separately for providing the radioisotope under codes 78990 (provision of diagnostic radiopharmaceutical[s]), A4642 (supply of satumomab pendetide, radiopharmaceutical diagnostic imaging agent, per dose), A9500 (technetium Tc 99m sestamibi, per dose), A9502 (technetium Tc 99m tetrofosmin, per unit dose), A9503 (technetium Tc 99m, medronate, up to 30 mCi) and A9505 (thallous chloride TL-201, per mCi), as appropriate. As of Jan. 1, 2000, A9504 (technetium Tc 99m apcitide) also may be billed. Because Medicare carriers have the final say on these matters, however, Cathey recommends you check with your carrier to determine if it will reimburse the supplies.