Medical Policies Online - Policy #: 03.02.12b

Claim Payment Policy

Title:

Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)

Policy #:

03.02.12b

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company's claims processing logic for procedure codes representing electrocardiograms (ECG/EKG) (12-lead or more) when reported with procedure codes representing single photon emission computed tomography (SPECT) for myocardial perfusion imaging (MPI).

Description

A twelve-lead electrocardiogram (ECG/EKG) records the electrical impulses that stimulate the contractions of the heart and can indicate dysfunctions that influence the conduction ability of the myocardium (cardiac muscle).

Single photon emission computed tomography (SPECT) provides slices of three-dimensional images of internal anatomy and blood flow. Myocardial perfusion imaging (MPI) is the assessment of blood flow through the heart muscle under stress and/or rest conditions.

Policy

When an electrocardiogram (ECG/EKG) (12-lead or more) procedure code (93000, 93005, 93010) is reported with a code representing single photon emission computed tomography (SPECT) for myocardial perfusion imaging (MPI) (78464, 78465), and performed on the same date of service by the same provider, both codes are processed for separate reimbursement consideration.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

This claim payment rationale applies only to the code combinations addressed within this policy and does not apply to any other code combinations. Claims are processed according to the statements in this policy.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The table below depicts the claims processing outcome when an electrocardiogram (ECG/EKG) code (column 1) is reported with a code representing single photon emission computed tomography (SPECT) for myocardial perfusion imaging (MPI) (column 2). This table is a complete list of applicable codes.

WHEN A CODE IN COLUMN 1 IS REPORTED WITH A CODE IN COLUMN 2, BOTH CODES ARE PROCESSED FOR SEPARATE REIMBURSEMENT CONSIDERATION
COLUMN I ECG/EKG	COLUMN 2 SPECT FOR MPI	OUTCOME
93000	78464	93000, 78464
93005	78464	93005, 78464
93010	78464	93010, 78464

93000	78465	93000, 78465
93005	78465	93005, 78465
93010	78465	93010, 78465

MEDICARE
This policy is consistent with Medicare Correct Coding Initiative (CCI) edits.

References

CC+Edit™[computer program]. NTIS Version 13.1, Release .01. MIT Solutions, Inc.; Copyright 2001-2006.

Empire Medicare Services. Article: Cardiovascular nuclear medicine - Coding guidelines for Local Coverage Determination (LCD) L3865. [Empire Medicare Services Web site]. Original: 05/02/94 (Revised: 01/01/07). Available at: http://www.empiremedicare.com/newjpolicy/policy/l3865_final_guideline.htm. Accessed February 25, 2008.

Empire Medicare Services. Local Coverage Determination (LCD). L3865: Cardiovascular nuclear medicine. [Empire Medicare Services Web site]. Original: 05/02/94 (Revised: 02/01/08). Available at: http://www.empiremedicare.com/newjpolicy/policy/l3865_final.htm. Accessed February 25, 2008

Encoder Pro Expert [computer program]. Version 5.1.0C. (with Medicare CCI edits from Version 13.3.) Ingenix, Inc.; 2007.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	78464, 78465, 93000, 93005, 93010
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	N/A

Revenue Codes	N/A

Cross References

Cross Reference Policies

09.00.32h:

Diagnostic and Therapeutic Radiopharmaceutical Agents

Version Effective Date: 03/26/2008