L28934 MYOCARDIAL PERFUSION IMAGING

 

 

04/15/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Myocardial perfusion imaging will be considered medically reasonable and necessary by Medicare if any one of the following circumstances is present:

o The patient has chest pain, other symptoms, or signs suggestive of coronary artery disease, and the patient has an abnormal baseline EKG:

 RBBB.

 LBB.

 IVCD.

 LVH.

 Atrial fibrillation.

 Marked resting ST segment changes.

• Which would make interpretation of a standard exercise test inaccurate.

o The patient has:

 Chest pain.

 Other symptoms.

 Signs suggestive of coronary artery disease.

And

 The patient is on:

• A cardiac glycoside (Digoxin).

• Other medication which would impair the accuracy of interpretation of a standard exercise test.

o The patient has an abnormal or non-diagnostic standard exercise test and myocardial perfusion imaging is being performed in order to determine if the patient has myocardial ischemia.

o The patient has a condition, such as mitral valve prolapse, which would likely result in a non-diagnostic or inaccurate standard stress test.

o Patient has known coronary artery disease (or recent myocardial infarction) and myocardial perfusion imaging is being done to determine the significance of/or the extent of myocardial ischemia (or scar) resulting from coronary artery disease or to assess myocardial viability.

o The patient has undergone cardiovascular re-perfusion (CABG, PTCA, thrombolysis) and perfusion imaging is being done to evaluate the effectiveness of the intervention.

o The patient has developed congestive heart failure and a silent MI is suspected.

o The patient has a ventricular wall motion abnormality demonstrated by another imaging modality and perfusion imaging is needed to further evaluate the abnormality.

o The patient has severe peripheral vascular disease and is a candidate for peripheral vascular reperfusion by balloon angioplasty or bypass surgery and myocardial perfusion imaging is being done pre-operatively because of concern about possible significant coronary artery disease.

o Follow-up within 48 hours of an abnormal multiple myocardial perfusion scan to determine whether the perfusion defect is related to myocardial scarring or myocardial ischemia.

 Usually only a single study is needed to evaluate this indication.

 

 

Coding Information

 

Bill Type Codes

 

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

71x Clinic - Rural Health

85x Critical Access Hospital

 

 

Revenue Codes

 

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0340 Nuclear Medicine - General Classification

0341 Nuclear Medicine - Diagnostic

0342 Nuclear Medicine - Therapeutic

0343 Nuclear Medicine - Diagnostic Radiopharmaceuticals

0344 Nuclear Medicine - Therapeutic Radiopharmaceuticals

0349 Nuclear Medicine - Other Nuclear Medicine

 

 

CPT/HCPCS Codes

 

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

78453 MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING 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)

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

 

 

ICD-9 Codes that Support Medical Necessity

 

411.0 POSTMYOCARDIAL INFARCTION SYNDROME

411.1 INTERMEDIATE CORONARY SYNDROME

411.81 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION

411.89 OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER

412 OLD MYOCARDIAL INFARCTION

413.0 ANGINA DECUBITUS

413.1 PRINZMETAL ANGINA

413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS

414.00 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT

414.01 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY

414.02 CORONARY ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT

414.03 CORONARY ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT

414.04 CORONARY ATHEROSCLEROSIS OF ARTERY BYPASS GRAFT

414.05 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT

414.06 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART

414.07 CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART

414.10 ANEURYSM OF HEART (WALL)

414.11 ANEURYSM OF CORONARY VESSELS

414.12 DISSECTION OF CORONARY ARTERY

414.19 OTHER ANEURYSM OF HEART

414.2 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY

414.3 CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE

414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE

414.9 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED

424.0 MITRAL VALVE DISORDERS

426.2 LEFT BUNDLE BRANCH HEMIBLOCK

426.3 OTHER LEFT BUNDLE BRANCH BLOCK

426.4 RIGHT BUNDLE BRANCH BLOCK

426.50 BUNDLE BRANCH BLOCK UNSPECIFIED

426.51 RIGHT BUNDLE BRANCH BLOCK AND LEFT POSTERIOR FASCICULAR BLOCK

426.52 RIGHT BUNDLE BRANCH BLOCK AND LEFT ANTERIOR FASCICULAR BLOCK

426.53 OTHER BILATERAL BUNDLE BRANCH BLOCK

426.54 TRIFASCICULAR BLOCK

426.6 OTHER HEART BLOCK

426.7 ANOMALOUS ATRIOVENTRICULAR EXCITATION

427.31 ATRIAL FIBRILLATION

428.0 CONGESTIVE HEART FAILURE UNSPECIFIED

428.1 LEFT HEART FAILURE

428.20 UNSPECIFIED SYSTOLIC HEART FAILURE

428.21 ACUTE SYSTOLIC HEART FAILURE

428.22 CHRONIC SYSTOLIC HEART FAILURE

428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE

428.30 UNSPECIFIED DIASTOLIC HEART FAILURE

428.31 ACUTE DIASTOLIC HEART FAILURE

428.32 CHRONIC DIASTOLIC HEART FAILURE

428.33 ACUTE ON CHRONIC DIASTOLIC HEART FAILURE

428.40 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.41 ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.42 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.43 ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.9 HEART FAILURE UNSPECIFIED

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

440.4 CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

794.39* OTHER NONSPECIFIC ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM

960.7 POISONING BY ANTINEOPLASTIC ANTIBIOTICS

995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.24 FAILED MODERATE SEDATION DURING PROCEDURE

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

E942.0* CARDIAC RHYTHM REGULATORS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E942.1* CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY

V67.09 FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY

V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

V67.59 OTHER FOLLOW-UP EXAMINATION

* According to the ICD-9-CM book, diagnosis codes E942.0 and E942.1 are secondary diagnosis codes and should not be billed as the primary diagnosis.

* ICD-9-CM code V58.69 should be used as a secondary code only and should not be billed as the primary diagnosis.

*ICD-9-CM code 794.39 should be used when an abnormal or non-diagnostic stress test is the reason myocardial perfusion imaging is being performed.

 

 

Documentation Requirements

 

• Medical record documentation maintained by the ordering/referring physician must clearly indicate the medical necessity of myocardial perfusion imaging studies.

o Also, the results of myocardial perfusion studies must be included in the patient's medical record. This information is normally found in the office/progress notes and/or test results.

• If the provider of myocardial perfusion imaging studies is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies.

• The medical record must document when significant resting ECG abnormalities are present, or a medication is being used and cannot be withdrawn, that would interfere with the interpretation of a stress ECG, resulting in the selection of a myocardial perfusion study.

• The rationale for selecting pharmacologic stress rather than exercise stress must be indicated in the medical record.

 

 

Treatment Logic

 

• Myocardial perfusion imaging is a cardiac radionuclide imaging procedure that is usually performed with exercise electrocardiogram ECG/EKG testing for detecting coronary artery disease and determining prognosis.

• The SPECT (single-photon emission computed tomographic) technique is utilized to obtain multiple-angle images.

 

 

Sources of Information and Basis for Decision

 

Acampa, W., Spinelli, L, Petretta, M, DeLauro, F, Ibello, F. & Cuocolo, A. (2005). Prognostic value of myocardial ischemia in patients with uncomplicated acute myocardial infarction: direct comparison of stress echocardiography and myocardial perfusion imaging [Electronic version]. Journal of Nuclear Medicine, 46:3, 417-423.

 

Chevrier, R. (2003). Myocardial perfusion imaging: what patients need to know [Electronic version]. Medscape Radiology, 4:1

 

Commission on Health Care Policy and Practice Guidelines and Communications Committee (2002). Society of nuclear medicine procedure guideline for myocardial perfusion imaging, version 3.0.

 

FCSO LCD 28934, Myocardial Perfusion Imaging, 04/15/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Hacker, M., et al. (2005). Comparison of spiral multidetector CT angiography and myocardial perfusion imaging in the noninvasive detection of functionally relevant coronary artery lesions: first clinical experiences. [Electronic version]. Journal of Nuclear Medicine, 46:8, 1294-1300.

 

National Guideline Clearinghouse (2005). Procedure guideline for myocardial perfusion imaging. Retrieved November 3, 2005, from www.guideline.gov.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

LCD L28934 MYOCARDIAL PERFUSION IMAGING