Radiology Coding Alert

Identify SPECT with ease to cut down on denials
 
The National Correct Coding Initiative's latest edits put a halt to reporting cardiac blood pool imaging with SPECT - stumping coders who want to report 78465 with 78472's add-on code CPT 78496 for a gated first pass of the right ventricle. We've got your best bet for reimbursement when you perform a SPECT and right ventricle gated first pass together. Edit Your SPECT Coding As of April 1, you can no longer report 78472 (Cardiac 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) when you report 78465 (Myocardial perfusion imaging; 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).
 
NCCI Edits says these are mutually exclusive procedures that carry a modifier indicator status of "0," meaning you cannot use modifiers to separate them. And if you report both, Medicare will only reimburse you for the lesser-valued of the two procedures.

"This doesn't come as too much of a surprise," says Cynthia A. Swanson, RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb. Many local coverage determinations already say they typically won't cover cardiac blood pool codes and perfusion imaging codes on the same date of service.

The reason is "limitations of uptake, low-photon energy and redistribution," according to National Heritage Insurance Company's Northern California LCD. Never Report Undocumented Procedures You'll often see reports for 78465, a SPECT study checking to see how the coronary arteries are supplying blood to the myocardium (cardiac muscle responsible for the function of the four chambers of the heart), says Bart Outzen, RT, RT(N), CNMT, director of nuclear medicine at Cardiovascular Physicians PA in Greenville, Miss.

At the same session, the physician may perform the services described in +78496 (Cardiac 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]).

Mistake: CPT says to use 78496 only in conjunction with 78472, so some coders report an unperformed 78472 to justify reporting 78496.
 
Disaster averted: If you see a report that seems to merit 78465 and 78496, steer clear of throwing in 78472 just for payment. If you report SPECT 78465 with 78472 when the physician doesn't document 78472, a denial for not following NCCI is the least of your worries - you could be facing fraud charges, assuming a pattern of erroneous coding can be attributed to purposeful miscoding with the intent to achieve payment for services not [...]