Cardiology Coding Alert

Question: How should I report the following case? A patient with an abnormal ECG presents for SPECT imaging at rest with 15 mCi of Tc-99m sestamibi. Then the patient received 6 mg of adenosine and another dose of Tc-99m sestamibi for stress imaging (non-gated). We provide the full stress test service.

Missouri Subscriber

Answer: If the cardiologist documents a diagnosis based on the test, you should code that diagnosis. If not, you should report the code that represents the reason for the test. In this case, that is the abnormal electrocardiogram (ECG), for which you should report 794.31 (Nonspecific abnormal electrocardiogram [ECG] [EKG]).

To report the SPECT imaging both at rest and stress, report a single unit of 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).

Because you perform the full stress test service (all components), you should report a single unit of 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).

Finally, if your practice provided the radiopharmaceutical and stress agents, you'll need to report HCPCS codes for them.

The appropriate reporting for the adenosine is 1 unit of J0152 (Injection, adenosine for diagnostic use, 30 mg [not to be used to report any adenosine phosphate compounds; instead use A9270]).

For the sestamibi, report A9500 (Technetium Tc-99m sestamibi, diagnostic, per study dose). The code specifies that you should report one unit per study dose. For many payers, that means that you should report two units if the patient receives one dose for rest and one dose for stress.

For example: In coding and billing guidelines attached to its local coverage determination (LCD), Wisconsin Physicians Service, the Part B MAC for Missouri, indicates that "if two (2) per study doses of these agents are used, one for rest and one for the stress portion of the study, it would be billed as two (2) units." (To find this document, search by Document ID L31072 at www.cms.gov/medicare-coverage-database/. Once you access the LCD scroll to the bottom to find links to attachments.)

Other payers may consider rest plus stress to be a single study and require you to report a single unit.