Last Modified: 6/29/2023
Location: FL, PR, USVI
Business: Part B
First Coast has identified positron emission tomography (PET) myocardial perfusion imaging (MPI) studies (CPT codes 78491 and 78492) and Rb-82 rubidium (HCPCS code A9555, used with MPI PET), as top claim denials for claims reviewed by the recovery audit contractor (RAC) during 2021. The main category of errors were for medically unnecessary services or no documentation received when requested. We'd like to remind providers of the documentation requirements to avoid denials of these services.
An MPI PET is when the provider performs a PET scan, a type of nuclear imaging test, of the heart revealing how blood flows through the heart. The service includes ventricular wall motion and ejection fraction or both, if performed. This can be provided with or without cardiac stress testing.
A cardiac or cardiovascular stress test, also referred to as exercise stress test, exercise electrocardiogram (ECG), an exercise treadmill test, graded exercise test, or stress ECG, is used to provide information about how the heart responds to exertion.
CPT code 78491 is used for a single MPI PET study performed at rest or stress, which can be exercise or drug induced. CPT code 78492 is for multiple MPI PET studies performed at rest or stress.
A drug induced or pharmacologic stress test may be performed when patients are unable to exercise. This test involves the administration of a medication designed to make the heart respond as if the patient was exercising. The pharmacologic testing allows the provider to determine how the heart responds to stress in the absence of exercise.
Refer to First Coast's LCD L38396
Cardiology non-emergent outpatient stress testing and local coverage billing & coding article (LCA) A56952
for utilization guidelines applying to the reasonable and necessary provisions outlined.
This LCD and LCA apply to and include the following non-emergent outpatient cardiovascular stress testing procedures:
• Cardiovascular stress test (exercise and pharmacological stress)
• Echocardiography (rest and stress)
• MPI PET (rest or stress)
• MPI single photon emission computed tomography (SPECT) (rest or stress)
• Cardiac magnetic resonance imaging (MRI) with stress imaging
All PET scan services require the use of a radiopharmaceutical diagnostic imaging agent (tracer). The applicable tracer code should be billed for the same date of service when billing for a PET scan service. HCPCS code A9555 is used for billing rubidium 82 (Rb-82).
Medicare covers one PET scan for imaging of the perfusion of the heart using Rb-82, provided the following conditions are met:
• PET is done at an imaging center with a PET scanner approved by the FDA;
• PET scan is a rest alone or rest with pharmacologic stress PET scan, used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease, using Rb-82; and
• Either the PET scan is used in place of, but not in addition to, an MPI SPECT or the PET scan is used following an inconclusive SPECT.
If either of the codes (PET scan CPT code or tracer code) are denied or not covered, the other code will also deny. We recommend billing these services on the same claim to expedite processing and to avoid claim rejections.
For more details regarding tracer agents, refer to MLN Matters article MM 10319
All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Here are the documentation requirements from the LCA:
• Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
• The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT or HCPCS code must describe the service performed. The billing and coding article A56952 (linked above) provides billing and coding guidance for diagnosis limitations supporting diagnosis to procedure code automated denials.
• If the provider of the service is other than the ordering or referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering or referring physician's order for the studies.
• The ordering physician must state the clinical indication and medical necessity for the study in the order for the test.
• Documentation must be maintained by the referring physician in the beneficiary's medical record that the required conditions for the stress test performed have been met, as indicated in the "Coverage Indications, Limitations and Medical Necessity" section of the LCD.
• The rationale for selecting pharmacologic stress testing rather than exercise stress testing must be documented in the medical record.
• In the instance where regional wall motion abnormalities and ejection fraction have been assessed during the same episode of care by other testing modalities (e.g., echocardiography), the medical necessity of repeating this assessment with nuclear imaging modalities must be clearly documented in the medical record.
• All segments of the service must have a formal interpretation and report.
Refer to LCD L38396 (linked above) for coverage indications and limitations when stress testing with or without cardiac imaging will be considered medically reasonable and necessary.
Providers who perform these cardiovascular stress testing procedures should familiarize themselves with the LCD and LCA (linked above) and ensure to bill claims for these procedures with the required diagnosis codes. Be sure to bill required dual diagnoses, or a second diagnosis code on the original claim
when required. Remember -- It's the provider's responsibility to select codes to the highest level of specificity selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
Before submitting the claim, remember:
• Review the long descriptors for the CPT or HCPCS code you are billing. The short descriptors are limited to 28 characters, and they do not always capture the complete description of the procedure.
• Use the correct HCPCS code to describe the tracer agent used during the procedure.
• When a PET tracer code is present on a claim, the claim must also contain an appropriate PET CPT code and vice versa
• Ensure your documentation supports the code(s) being billed
• If documentation should be requested, be sure to respond timely with proper records to the requesting contractor
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