Wiki Myocardial Perfusion Study

KoBee

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I been coding 93016/93018 and wasn't sure if I should be including CPt 78451 or 78452... want to make sure im capturing this correctly on the professional side :( HELP!


Cardiologist: A
Myocardial Perf. Study
Myocardial Perf.
Date of Procedure: 04/16/19
Indication:
negative troponins
CP
Findings:
chart reviewed
Impression/conclusion:
In a fasting state, the patient was taken to the nuclear medicine department where he was monitored continuously. A
stress adenosine was performed according to protocol. The patient had SOB and flushing during the infusion and
remained hemodynamically stable. Baseline EKG SR J point elevation inferior and lateral leads without acute changes
during the test. Nuclear images pending.



Tech:
NM CARDIAC STRESS SCAN W/DRUGS
NUCLEAR MEDICINE MYOCARDIAL PERFUSION SCAN

History: Chest pain.

Procedure:

The patient underwent stress testing with infusion of Lexiscan, using
established protocol, with injection of 32 mCi of 99m Tc Cardiolite.

A resting myocardial perfusion imaging study was also performed, with
injection of 4.3 mCi of thallium 201 chloride.

Single photon emission computed tomography was employed to generate
tomographic images of the left ventricle, stress and resting and gated
rest and stress SPECT was also acquired to evaluate wall motion and
ejection fraction.

Findings:

There are focal areas of decreased perfusion on the stress portion of
the exam in the inferior wall of the left ventricle with improved
perfusion on the rest portion of the exam to suggest reversible
ischemia.

Sum stress score is 3, sum rest score is0 and sum difference score is
3.

The left ventricle demonstrates normal wall motion. The estimated
ejection fraction is 68%.

There is no left ventricular dilatation.


IMPRESSION:

1. Reversible ischemia in the inferior wall of the left ventricle.

2. Normal left ventricular wall motion.

3. Calculated ejection fraction of 68%.
 
Just wanted to add that am only coding for the professional, I have the cardiologist reading the results but then I have another report where the tech transcribes the results with another md signing off ... that is what throws me off a little ..

Do I only code the 93016 & 93018 for the cardiologist and the MD signing off the images, will he bill for 78452 -26 OR does the cardiologist bill for all 93016/93018/78452-26 ... I'm getting myself so confused:(


This was done at the hospital
 
Coding Data Analyst

Just wanted to add that am only coding for the professional, I have the cardiologist reading the results but then I have another report where the tech transcribes the results with another md signing off ... that is what throws me off a little ..

Do I only code the 93016 & 93018 for the cardiologist and the MD signing off the images, will he bill for 78452 -26 OR does the cardiologist bill for all 93016/93018/78452-26 ... I'm getting myself so confused:(


This was done at the hospital

The Cardiologist would bill for the 93016-93018 codes and the Radiologist would bill for the 78451-78454 codes. The Radiologist should be reading the report.
 
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