Reimbursement & Coding Procedures

Reimbursement

Navigating the reimbursement process can be a challenging task for all physicians. Nuclear cardiology faces unique payment and practice management issues in both the public and private sectors. View the topics below to find summaries of important developments in nuclear cardiology reimbursement.

• ​​2021 (and Prior) MPFS and HOPPS Payment Charts - Member only access
• PET Model Coverage Policy
• SPECT Model Coverage Policy
• ASNC MiBG Letter
• Test Substitution Toolkit

ASNC, Partner Groups Submit Comments on Cardiac PET Reimbursement to CMS

On February 10th, ASNC, SNMMI, and ACC submitted a joint letter to CMS as part of an ongoing effort to ensure fair and accurate payment for PET services. The groups’ comments focus on providing additional information to correct direct practice expense inputs and how societies may be able to provide more comprehensive information on indirect costs for practice expense. The associations recommended the status quo of contractor pricing until recommendations from a CMS-convened technical expert panel can be analyzed or until acceptable information can be provided. Read the full letter.

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Coding Information

Coding Tips
Given the numerous changes to billing and coding procedures for nuclear cardiology implemented annually, ASNC offers a series of articles to help practitioners who work with Medicare and private carriers secure appropriate reimbursement for nuclear cardiology services.

Basic Coding Guidance for Billing MPI SPECT - Part 1
Released June 2010
 

Coding Alert:  ASNC Identifies Incorrect NCCI Edits, Pursuing Remedy

ASNC has learned that there are more than a dozen incorrect edits in the National Correct Coding Initiative (NCCI) pertaining to new and revised CPT codes that went into effect January 1, 2020. Please share this information with your coding team. The Centers for Medicare & Medicaid Services (CMS) deleted the following procedure-to-procedure (PTP) edits:

Other identified errors for Nuclear Cardiology include --  CPT 78429 Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries edit is a 1. We disagree and have requested the removal of edit common tracer for this procedure.   CPT 78430 edit with A9555 Rubidium-82, diagnostic, per study dose, up to 60 millicuries edit is a 1. We disagree and have requested the removal of edit common tracer for this procedure, common perfusion tracer.  New below --  Cardiac PET (CPT 78492) with the A9555 for rubidium. Now, just the 78492 is being denied M20 missing/incomplete/invalid HCPCS. We called CMS and were told to add A9597 or A9598 code, which indicates tumor or no tumor; this is wrong as those are oncologic.

Next Steps ASNC is in discussions with both CMS and the American Medical Association about the NCCI edit errors. For now, we recommend the following: Continue billing as usual.   Be aware that the line item radiopharmaceutical may deny payment, but you must continue to bill for the radiopharmaceutical so that when the edit is corrected providers can be appropriately reimbursed.   You may choose to appeal the denial of the radiopharmaceutical. You may share this communication with your Medicare Administrative Contractor (MAC) so the MAC understands that an incorrect NCCI edit has been identified. The MAC is required to pay on any edit until it is identified by CMS as an error. They may ask for the claim to be appealed or issue a mass adjustment. Any mass adjustment would be made after the NCCI accepts and approves the errors. At this point, ASNC is unsure how all these edits will be handled.  To report an issue with a code pair, email glawrence@asnc.org.