LCD Reference Article Billing and Coding Article

Billing and Coding: Cardiovascular Nuclear Medicine

A56743

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
N/A
Article ID
A56743
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Cardiovascular Nuclear Medicine
Article Type
Billing and Coding
Original Effective Date
08/01/2019
Revision Effective Date
10/01/2023
Revision Ending Date
N/A
Retirement Date
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CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

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Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Cardiovascular Nuclear Medicine.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Medical records must substantiate the medical necessity of the services, including a clinical diagnosis and the specific reason for the study.

All segments of the service must have a formal interpretation and report.

The referral order must include the medical indication for the study, and be kept on file in the patient's medical record.

When CPT code 78472 and add-on code 78496 are submitted with perfusion codes 78451-78454, the formal reports must document that simultaneous cardiac function studies using the first pass technique were performed and that the laboratories are equipped to perform such studies.

When a blood pool scan is performed to assess ejection fraction prior to implantation of defibrillator or biventricular pacemaker, the record must document the intended plan for insertion and the result of the test.

When billing for the purchase of radiopharmaceutical(s), a copy of the bill indicating the dosage administered, unit price per dose, name and total charge of the radiopharmaceutical must be on file in the patient's medical record and available on request.

Utilization Guidelines:

Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years would be reimbursable; otherwise tests repeated in the absence of changes in cardiac signs or symptoms will be considered not medically necessary.


 

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(195 Codes)
Group 1 Paragraph

The use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the attached determination.

ICD-10-CM codes for Perfusion with or without Functional Studies: CPT codes 78451, 78452, 78453, 78454, 78472, 78473, 78481, 78483

Use ICD-10 code Z01.810 for those tests which were performed to evaluate pre-operative risk (see Indications section in the LCD) but for whom the test was negative. (A positive test should be coded with the results of the test.)

Group 1 Codes
Code Description
I20.0 Unstable angina
I20.1 Angina pectoris with documented spasm
I20.81 Angina pectoris with coronary microvascular dysfunction
I20.89 Other forms of angina pectoris
I20.9 Angina pectoris, unspecified
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I21.9 Acute myocardial infarction, unspecified
I21.A1 Myocardial infarction type 2
I21.A9 Other myocardial infarction type
I21.B Myocardial infarction with coronary microvascular dysfunction
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I23.0 Hemopericardium as current complication following acute myocardial infarction
I23.3 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction
I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
I23.7 Postinfarction angina
I23.8 Other current complications following acute myocardial infarction
I24.0 Acute coronary thrombosis not resulting in myocardial infarction
I24.1 Dressler's syndrome
I24.81 Acute coronary microvascular dysfunction
I24.89 Other forms of acute ischemic heart disease
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.2 Old myocardial infarction
I25.3 Aneurysm of heart
I25.41 Coronary artery aneurysm
I25.42 Coronary artery dissection
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris
I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris
I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris
I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris
I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris
I25.82 Chronic total occlusion of coronary artery
I25.83 Coronary atherosclerosis due to lipid rich plaque
I25.84 Coronary atherosclerosis due to calcified coronary lesion
I25.85 Chronic coronary microvascular dysfunction
I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
I42.0 - I42.9 Dilated cardiomyopathy - Cardiomyopathy, unspecified
I44.7 Left bundle-branch block, unspecified
I46.2 Cardiac arrest due to underlying cardiac condition
I46.8 Cardiac arrest due to other underlying condition
I46.9 Cardiac arrest, cause unspecified
I47.0 Re-entry ventricular arrhythmia
I47.10 Supraventricular tachycardia, unspecified
I47.11 Inappropriate sinus tachycardia, so stated
I47.19 Other supraventricular tachycardia
I47.20 Ventricular tachycardia, unspecified
I47.21 Torsades de pointes
I47.29 Other ventricular tachycardia
I47.9 Paroxysmal tachycardia, unspecified
I48.0 Paroxysmal atrial fibrillation
I48.11 Longstanding persistent atrial fibrillation
I48.19 Other persistent atrial fibrillation
I48.20 Chronic atrial fibrillation, unspecified
I48.21 Permanent atrial fibrillation
I48.91 Unspecified atrial fibrillation
I49.01 Ventricular fibrillation
I49.02 Ventricular flutter
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified
I51.3 Intracardiac thrombosis, not elsewhere classified
I51.81 Takotsubo syndrome
I51.89 Other ill-defined heart diseases
Q24.5 Malformation of coronary vessels
R06.00 Dyspnea, unspecified
R06.02 Shortness of breath
R06.03 Acute respiratory distress
R06.09 Other forms of dyspnea
R06.83 Snoring
R06.89 Other abnormalities of breathing
R07.2 Precordial pain
R07.82 Intercostal pain
R07.89 Other chest pain
R07.9 Chest pain, unspecified
R94.31 Abnormal electrocardiogram [ECG] [EKG]
T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.817D Embolism due to cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.817S Embolism due to cardiac prosthetic devices, implants and grafts, sequela
T82.827A Fibrosis due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.827D Fibrosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.827S Fibrosis due to cardiac prosthetic devices, implants and grafts, sequela
T82.837A Hemorrhage due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.837D Hemorrhage due to cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.837S Hemorrhage due to cardiac prosthetic devices, implants and grafts, sequela
T82.847A Pain due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.847D Pain due to cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.847S Pain due to cardiac prosthetic devices, implants and grafts, sequela
T82.855A Stenosis of coronary artery stent, initial encounter
T82.855D Stenosis of coronary artery stent, subsequent encounter
T82.855S Stenosis of coronary artery stent, sequela
T82.856A Stenosis of peripheral vascular stent, initial encounter
T82.856D Stenosis of peripheral vascular stent, subsequent encounter
T82.856S Stenosis of peripheral vascular stent, sequela
T82.857A Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter
T82.857D Stenosis of other cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.857S Stenosis of other cardiac prosthetic devices, implants and grafts, sequela
T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.867D Thrombosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.867S Thrombosis due to cardiac prosthetic devices, implants and grafts, sequela
T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter
T82.897D Other specified complication of cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.897S Other specified complication of cardiac prosthetic devices, implants and grafts, sequela
T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter
T82.9XXD Unspecified complication of cardiac and vascular prosthetic device, implant and graft, subsequent encounter
T82.9XXS Unspecified complication of cardiac and vascular prosthetic device, implant and graft, sequela
T86.20 Unspecified complication of heart transplant
T86.21 Heart transplant rejection
T86.22 Heart transplant failure
T86.23 Heart transplant infection
T86.290 Cardiac allograft vasculopathy
T86.298 Other complications of heart transplant
T86.30 Unspecified complication of heart-lung transplant
T86.31 Heart-lung transplant rejection
T86.32 Heart-lung transplant failure
T86.33 Heart-lung transplant infection
T86.39 Other complications of heart-lung transplant
Z01.810 Encounter for preprocedural cardiovascular examination
Z48.21 Encounter for aftercare following heart transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z94.1 Heart transplant status
Z94.3 Heart and lungs transplant status
Z95.1 Presence of aortocoronary bypass graft
Z95.5 Presence of coronary angioplasty implant and graft
Z98.61 Coronary angioplasty status

Group 2

(24 Codes)
Group 2 Paragraph

ICD-10-CM codes for Cardiac Blood Pool Studies: CPT codes 78472, 78473, 78481, 78483, 78494 and 78496

  • Report ICD-10 code Z01.818 when the test is performed as a baseline study before chemotherapy
  • Report ICD-10-CM code Z51.81 for subsequent monitoring while the patient is receiving chemotherapy.
  • Report ICD-10-CM code Z08 for testing when chemotherapy is completed.
  • ICD-10 codes I50.20, I50.21, I50.22, I50.23, I50.40, I50.41, I50.42, I50.43, I50.810-I50.814, I50.82-I50.84 and I50.89 will be considered to support medical necessity only when performed to calculate ejection fraction in those patients being actively considered for defibrillator or biventricular pacemaker placement, where ejection fraction is a determining factor in the decision.

Group 2 Codes
Code Description
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
Z01.30 Encounter for examination of blood pressure without abnormal findings
Z01.818 Encounter for other preprocedural examination
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z51.11 Encounter for antineoplastic chemotherapy
Z51.12 Encounter for antineoplastic immunotherapy
Z51.81 Encounter for therapeutic drug level monitoring

Group 3

(25 Codes)
Group 3 Paragraph

ICD-10-CM Codes for Infarct avidity studies only: CPT 78466, 78468 and 78469

Group 3 Codes
Code Description
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I21.9 Acute myocardial infarction, unspecified
I21.A1 Myocardial infarction type 2
I21.A9 Other myocardial infarction type
I21.B Myocardial infarction with coronary microvascular dysfunction
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
I25.82 Chronic total occlusion of coronary artery
I25.85 Chronic coronary microvascular dysfunction
R07.2 Precordial pain
R07.82 Intercostal pain
R07.89 Other chest pain
R07.9 Chest pain, unspecified
R94.31 Abnormal electrocardiogram [ECG] [EKG]
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1 Codes

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ICD-10-PCS Codes

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Group 1 Codes

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Additional ICD-10 Information

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

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2023 R5

Due to the annual ICD-10 updates for 2024, the following coding has been revised:

For group 1:

  • ICD-10 code 120.8 has been deleted and codes I20.81 and I20.89 were added
  • ICD-10 code I24.8 has been deleted and codes I24.81 and I24.89 were added 
  • ICD-10 code I47.1 has been deleted and codes I47.10, I47.11 and I47.19 were added
  • ICD-10 codes I25.85 and I21.B have been added

For group 3, ICD-10 codes I25.85 and I21.B have been added

10/01/2022 R4

ICD-10 code I44.7 has been added to Group 1 covered diagnoses.

10/01/2022 R3

Due to the annual ICD-10 code updates for 2023, ICD-10 code I47.2 is deleted and replaced by I47.20, I47.21 and I47.29 in Group 1.

07/01/2021 R2

Article revised to add ICD-10 codes I47.0, I47.1, I47.2 and I47.9 to Group 1 as covered.

10/01/2019 R1

Article revised for annual ICD-10 updates for 2020. ICD-10 codes I48.11, I48.19, I48.20, and I48.21 replaced deleted codes I48.1 and I48.2 in Group 1.

The article was converted to the new Billing and Coding Article type.

Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33560 - Cardiovascular Nuclear Medicine
Related National Coverage Documents
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