Notification

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


Notification Issue Date: 12/27/2019

Effective 03/30/2020, this policy will be archived and no longer available.



Medicare Advantage Policy


Title:Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
Policy #:MA03.015

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

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.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.

Notification


Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.



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) (78451, 78452), 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.
Notification

Policy 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
78451
93000, 78451
93005
78451
93005, 78451
93010
78451
93010, 78451
93000
78452
93000, 78452
93005
78452
93005, 78452
93010
78452
93010, 78452


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

Description



A 12-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.
Notification

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.
Notification


Coding

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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

Notification

CPT Procedure Code Number(s)

78451, 78452, 93000, 93005, 93010


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements

Notification


Policy History

01/01/2015This is a new policy.
Notification





Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: N/A