CPT CODE 78451, 78452 – SPECT – Myocardial perfusion imaging, tomographic

by | Feb 12, 2022 | CPT modifiers

CPT code and Description

78451: 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); single study, at rest or stress (exercise or pharmacologic)

CPT® 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 .

• In a Non-Hospital Outpatient setting both imaging radiopharmaceuticals and stressing agents are paid separately. For imaging radiopharmaceuticals payment is based on either AWP or per invoice depending on the local Medicare Administrative Contractor (MAC) reimbursement payment methodology. For stressing agents, payments are based on AWP.

• In a Hospital Outpatient Department under Medicare both diagnostic radiopharmaceuticals (not on pass through status) and stressing agents are packaged into the APC payment rate.

Q: Which CPT codes should be used when describing MPI SPECT studies?

A: 78451: 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); single study, at rest or stress (exercise or pharmacologic)
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 93015-93018: Cardiovascular stress testing. Choose appropriate code(s) from the stress test series.
* Note: Also bill any appropriate HCPCS code for the use of radiopharmaceuticals or drugs administered during the MPI study or stress test.*

Q: The above example used 78452 to describe the imaging study. Can I use any of the CPT codes that describe MPI SPECT?
A: No! When deciding which code to use for any procedure, it is critical that coders select the name of the procedure or service that accurately identifies the service performed and not just choose a CPT code that merely approximates the service provided.

CPT/HCPCS Number Code of Units Description
78452 1 MPI, SPECT, multiple
A9500 2 99mTc sestamibi per study dose
93015* 1 Cardiovascular stress test,w interpretation and report
J0152 2 Adenosine per 30 mg

Q: Occasionally we are not able to gate a study and are not able to obtain a wall motion. If we do not perform wall motion does that mean we cannot bill CPT 78452?
A: No. The new parenthetical — (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed) — was structured to indicate that when wall motion and ejection fraction are performed, it would be considered to be inclusive in this newly bundled CPT code. However, if either is not performed, then it is still acceptable to use this code.

Q: Is it appropriate to bill the above cardiac stress test codes in conjunction with CPT 78452 since the code describes MPI SPECT studies performed at rest and/ or stress?
A: Stress testing is often used in conjunction with several nuclear cardiology procedures. CPT is clear in the cardiovascular introductory section (as noted below) for providers to code and bill separately for the stress test, in addition, to the nuclear cardiology procedure.
CPT states, “Myocardial perfusion and cardiac blood pool imaging studies may be performed at rest and/or during stress. When per formed during exercise and/or pharmacologic stress, the appropriate stress testing code from the 93015 to 93018 series should be reported in addition to code(s) 78451, 78452, 78453, 78454, 78472, 78473, 78481, 78491, and 78492.”

cpt code 78452 Most asked questions

what is the difference between cpt code 78452 and 78454 ?

  CPT 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.

 Provider performs multiple SPECT studies of the heart to determine the areas of deficient blood flow

  CPT 78454 - Myocardial perfusion imaging, planar (including 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
              Provider performs multiple planar studies of the heart to determine the areas of deficient blood flow.

how often can cpt 82962 be billed?
Only once per month

cpt 78452 medicare coverage?

Patients with low or intermediate pre-test probability for CAD who are exhibiting cardiac symptoms, including otherwise unexplained angina equivalent symptoms with normal or minor changes in resting ECG and no contraindications to exercise.

Patients with diabetes mellitus who are exhibiting cardiac symptoms, including otherwise unexplained angina equivalent symptoms, with normal or minor changes in resting ECG and no contraindications to exercise.

New-onset atrial fibrillation (with no prior cardiac evaluation).

Determining functional capacity and response to therapy in patients with hypertrophic cardiomyopathy.

Patients with an intermediate or high CHD risk (ATP III risk criteria) who have experienced syncope (an abrupt, transient, complete loss of consciousness) and cardiac etiology is suspected based on an initial evaluation, including history, physical examination, or ECG and the patient is able to exercise

Patients without cardiac symptoms who underwent a percutaneous coronary intervention (PCI) (with a stent) procedure more than 2 years prior or a coronary artery bypass graft (CABG) more than 5 years prior and have not undergone an evaluation for CAD within the past 2 years (stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography [CCTA], cardiac catheterization) and are able to exercise

what does cpt code 78451 mean ?
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); single study, at rest or stress (exercise or pharmacologic)

Myocardial Perfusion Imaging, Tomographic

78451 78452

Example #1:
An authorization is given for CPT code 78451 “Myocardial perfusion imaging, tomographic (SPECT); single study, at rest or stress”.

The cardiologist performs CPT code 78452 “Myocardial perfusion imaging, tomographic (SPECT); multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection”.

The provider does not need to contact Care to Care to modify the authorization as CPT code 78452 is included in the same code group as CPT code 78451.

Policy Statement

When a separate charge is reported for cardiovascular stress testing (procedure code 93015 or 93018), the stress test is eligible in addition to the allowance for the nuclear study. However, if two cardiovascular stress studies are performed on the same day in conjunction with exercise and resting nuclear studies, only one of the cardiovascular stress studies is eligible for reimbursement.

A pharmacological agent [e.g., Persantine (dipyridamole) (J1245); Adenosine (J0153)] may be used as an alternative to exercise in those patients who cannot perform an adequate level of exertion. Payment may be made for the agent, in addition to the allowance for the radionuclide cardiovascular stress test.

Payment can be made for either a planar (standard 78453 and 78454) or single photon emission computed tomography (SPECT 78451 and 78452) study. However, when both are performed for the same patient at the same time and reported separately, only the SPECT study is eligible for reimbursement, since the planar views can be obtained from the SPECT study.

When a radiopharmaceutical diagnostic imaging agent is reported in conjunction with a covered nuclear medicine study, payment may be made for the agent under the appropriate code for the radiopharmaceutical administered. The diagnostic imaging agent used in conjunction with an eligible imaging procedure is also eligible for reimbursement, when administered by the health care professional in a setting other than a hospital or a skilled facility.

Indications:
A cardiovascular stress test (pharmacologic and non-pharmacologic) will be considered medically reasonable and necessary for the following conditions:
Stress Testing without Imaging: For the diagnosis of suspected and prognosis of coronary artery disease in patients with normal or minor changes in resting ECG and no contraindications to exercise.

Stress Testing with Imaging:
Imaging stress tests addressed in this LCD include stress echocardiography and SPECT or PET nuclear myocardial perfusion imaging (MPI).
Stress testing with imaging can be performed with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine or adenosine analogs).

Stress echo and SPECT MPI are considered equivalent diagnostic tests. However, in addition to myocardial ischemia, stress echo can provide additional information that is not obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic obstruction. The most commonly performed myocardial perfusion imaging are single (at rest or stress, CPT code 78451) and multiple (at rest and stress, CPT code 78452) tomographic SPECT studies. Evaluation of the individual’s left ventricular wall motion and ejection fractions are routinely performed during SPECT MPI and are included in the code’s definition. Attenuation correction, when performed, is included in the MPI service.

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.

Procedures that Span Multiple Days

During our meeting on March 30th, we presented how the acquisition of some imaging data, particularly in nuclear medicine, must span several days, which could be as long as 10 or more days following the initial injection of the radiopharmaceutical (RP). Examples of such a typical procedure are; 78452 MPI, SPECT, multiple study imaging, where the stress study is performed on day one and the resting study is conducted on day two; in this instance there are two separate RP (such as A9500 or A9502) study doses on separate days and one CPT procedure code CPT 78452. The RPs would be billed on the DOS when administered, however the CPT procedure code 78452 could be billed on day one, day two or the span of day one through day two. All three options would be correct and are used based on the varying billing systems in place at the facilities doing the procedures. Two other examples are tumor imaging studies (CPT codes ranging 78800-78804): an Octreotide study, where the injection is administered on day one (A9572) and imaging performed over the next 48 hours; and Prostascint studies where the injection (A9507) is given on day one and the scan
occurs on day one and several days later.

During our meeting we noted the current inconsistent guidance from carriers/contractors on DOS for multiple day imaging, ranging from listing the span of start and end dates to one or the other as options selecting the date of radiopharmaceutical administration or selecting the last day imaging occurs today. Regarding the administration of any drug or radiopharmaceutical we believe it is important for CMS to clarify that the DOS would be the date any drug or radiopharmaceutical were administered to the patient. While we agree that consistency across carriers/contractors would be a nice to have for the procedure DOS, we do not believe it should be mandatory. For relative ease of implementation, we recommend that for procedures spanning multiple days (such as nuclear medicine imaging), CMS instruct contractors that the DOS remains at the provider discretion based on the systems they have in place. CMS’ decision to mandate any one of the three options for DOS requirement will necessitate changes for some providers’ systems. We further recommend and emphasize that sufficient lead-time be given by CMS to providers and their support system vendors before any required single policy change go into effect to allow adequate time for system modification and program changes.

EXERCISE NUCLEAR STRESS TEST

An Exercise Nuclear Stress Test or myocardial perfusion imaging (MPI) records heart rate, blood pressure and electrocardiogram response with exercise. It is used to evaluate blood flow to the heart. It is indicated if you suspect CAD or if an Exercise or Treadmill Stress Test did not pinpoint the cause of symptoms, such as chest pain or shortness of breath. During the test a small amount of radioactive tracer is injected intravenously into the bloodstream. A gamma camera detects the radiation released by the tracer to produce computer images of the heart. Combined with exercise, the test can help determine if there is adequate blood flow to the heart during activity vs. at rest, and if reduced blood flow is associated with ischemia or scar. During the exercise, the patient will walk on a treadmill to increase the heart rate. The speed and incline gradually increases (about every 3 minutes) until the target heart rate is met.

This is a “3 part test”, that is resting images are obtained under the gamma camera, then the patient is exercised, then images are obtained under the gamma camera following exercise. The Radiologist or Cardiologist will look at both the resting and exercise images for comparison.

  • For an EXERCISE NUCLEAR STRESS TEST a patient must be ABLE TO WALK briskly on an incline without assistive devices.
  • The patient should also realize they will need to lay on a narrow hard table under the gamma camera for resting images and for images following the exercise portion of the test (this may be a problem if they are claustrophobic).
  • An option for the claustrophobic is to provide medication for them, or order alternative test Exercise Stress Echo.
  • The patients should also realize this test takes about 3 to 5 hours to complete.

INDICATIONS

  • Diagnosis of coronary artery disease -Presence -Location (coronary territory) -Severity
  • Assessment of the impact of coronary stenosis on regional perfusion
  • Distinguish viable ischemic myocardium from scar
  • Risk assessment and stratification -Post myocardial infarction -Pre-operative for major surgery in patients who may be at risk for coronary events
  • Monitor treatment effect -After coronary revascularization -Medical therapy

ORDER

  • Stress Test Nuclear Exercise CPT Code 78452
  • Alternative test is Exercise Stress Echo CPT Code 93351
  • Patients must have a written prescription for the test

INSTRUCTIONS

  • Patient instructions are outlined on the LVHN Learn More About that you may give the patient.
  • DECISION POINT: To have patient HOLD beta blocker, or not. The (exercise) target heart rate may be difficult to achieve if beta blocker is not held, however, PCP needs to determine what is most appropriate for the patient according to patient’s medical condition(s)
  • Patients should NOT eat 4 hours before their test (note: in some instances the testing department may alter this instruction for example, if the patient is diabetic)
  • Patients should NOT eat or drink anything with caffeine 12 hours before their test (note: in some instances this is altered for example for an inpatient. Then a minimum of 1 hour is required)
  • Patients MAY drink non-alcoholic non-caffeine liquids as usual
  • DECISION POINT: IF the patient is diabetic, how the patient should take their diabetic medication on the day of the test.
  • Patients should STOP/REMOVE nitro (nitroglycerin) patch or nitro paste at least 2 HOURS before the test
  • Patients should NOT smoke at least 4 hours before the test.
  • If patients use an Inhaler they SHOULD bring their Inhaler with them to the test
  • Patients SHOULD wear appropriate shoes and clothing for walking on a treadmill
  • Patients should NOT use gels, oils, lotions, powders the day of the test
  • Patients MUST bring Insurance card and photo ID for registration/check-in the day of the test
  • Patients SHOULD call If they need to cancel the appointment