Medical Policy Advanced Imaging of the Heart CPT, HCPCS ...

Medical Policy Advanced Imaging of the Heart CPT, HCPCS and Diagnoses Codes

Policy Number: 971

BCBSA Reference Number: N/A NCD/LCD: N/A

Related Policies

? Medicare Advantage: Advanced Imaging/Radiology and Sleep Disorder Management Clinical and Utilization Guidance Redirect, #923

? Sleep Disorder Management, #969 ? Sleep Disorder Management CPT, HCPCS and Diagnoses Codes, #970 ? Advanced Imaging/Radiology, #968 ? Advanced Imaging/Radiology CPT and HCPCS Codes, #900 ? Advanced Imaging of the Heart, #972

Table of Contents

Commercial Products ............................................................................................................................................ 2 Medicare Advantage Products .............................................................................................................................. 2 Table 1. Nuclear Cardiology Infarct Imaging CPT 78466, 78468, 78469.............................................................. 2 Table 2. Nuclear Cardiology Myocardial Perfusion Imaging CPT 78451, 78452, 78453, 78454.......................... 2 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 .............................................................................................................................................................. 2 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 ............................................................. 2 Table 3. Nuclear Cardiology: Cardiac Blood Pool Imaging Blood Pool Imaging includes MUGA (Multi-Gated Acquisition) & First Pass Radionuclide Ventriculography CPT 78472, 78473, 78481, 78483, 78494, 78496...... 2 Table 4. Positron Emission Tomography (PET) Myocardial Imaging CPT 78429, 78430, 78431, 78432, 78433; 78434, 78491, 78492, 78459................................................................................................................................. 3 Table 5. Magnetic Resonance Imaging (MRI) Cardiac CPT 75557, 75559, 75561, 75563, 75565...................... 3 Table 6. Cardiac Computed Tomography (CT) for Quantitative Evaluation of Coronary Calcification CPT 75571 ............................................................................................................................................................................. 11 Table 7. Coronary CT Angiography (CCTA) and CT Derived Fractional Flow Reserve (FFR-CT) CPT 75574 . 11 Table 8. Computed Tomography (CT) Cardiac (Structure) CPT 75572, 75573 ................................................ 16

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Policy History ....................................................................................................................................................... 22 Disclaimer: ........................................................................................................................................................... 22

Commercial Products

The following CPT and HCPCS codes are in-scope under the AIM Advanced Imaging of the Heart Management Program for Commercial Managed Care (HMO and POS) and Commercial PPO and EPO. For medical necessity criteria, see AIM Clinical Appropriateness Guidelines for Advanced Imaging of the Heart.

Medicare Advantage Products

The following CPT and HCPCS codes are in-scope under the AIM Advanced Imaging of the Management Program for Medicare HMO and PPO. For medical necessity criteria, see AIM Clinical Appropriateness Guidelines for Advanced Imaging of the Heart.

Table 1. Nuclear Cardiology Infarct Imaging CPT 78466, 78468, 78469

The following codes may not be all-inclusive.

CPT Codes 78466 78468 78469

Code Description Planar, infarct avid; qualitative or quantitative Planar, infarct avid; with ejection fraction by first pass technique SPECT, infarct avid; with or without quantification

Table 2. Nuclear Cardiology Myocardial Perfusion Imaging CPT 78451, 78452, 78453, 78454

The following codes may not be all-inclusive.

CPT Codes 78451

78452

78453 78454

Code Description Myocardial perfusion imaging, tomographic (SPECT) (including attenuation co rrection, 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) 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 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) 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

Table 3. Nuclear Cardiology: Cardiac Blood Pool Imaging Blood Pool Imaging includes MUGA (Multi-Gated Acquisition) & First Pass Radionuclide Ventriculography CPT 78472, 78473, 78481, 78483, 78494, 78496

The following codes may not be all-inclusive.

CPT Codes 78472 78473 78481 78483 78494 78496

Code Description Gated equilibrium; planar, single study, wall motion plus ejection fraction Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction First pass technique; single study, wall motion study plus ejection fraction First pass technique; multiple studies, wall motion study plus ejection fraction Gated equilibrium: SPECT, at rest, wall motion study plus ejection fraction This code is an add-on code to be used in conjunction with 78472. As such, this code does not require separate review.

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Table 4. Positron Emission Tomography (PET) Myocardial Imaging CPT 78429, 78430, 78431, 78432, 78433; 78434, 78491, 78492, 78459

The following codes may not be all inclusive.

CPT codes 78429 78430

78431

78432 78433

78434 78491 78492 78459

Code Description Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) PET myocardial perfusion, single study PET myocardial perfusion, multiple studies PET myocardial, metabolic evaluation

Table 5. Magnetic Resonance Imaging (MRI) Cardiac CPT 75557, 75559, 75561, 75563, 75565

The following codes may not be all inclusive.

CPT codes 75557 75559 75561

75563

75565

Code Description Cardiac MRI for morphology and function, without contrast material Cardiac MRI for morphology and function, without contrast material, with stress imaging Cardiac MRI for morphology and function, without contrast material, followed by contrast material Cardiac MRI for morphology and function, without contrast material, followed by contrast material with stress imaging Add-on code to be used in conjunction with 75557, 75559, 75561, and 75563. As such, this code does not require separate review.

ICD-10 B33.22 C38.0 C38.1 C38.2 C38.3 C38.4 C38.8

Code Description Viral myocarditis Malignant neoplasm of heart Malignant neoplasm of anterior mediastinum Malignant neoplasm of posterior mediastinum Malignant neoplasm of mediastinum, part unspecified Malignant neoplasm of pleura Malignant neoplasm of overlapping sites of heart, mediastinum and pleura

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C78.1 C79.89 D15.1 D56.0 D56.1 D56.8 D56.9 D57.1 D57.40 D86.0 D86.85 D86.89 D86.9 E83.110 E83.118 E83.119 E85.4 E85.9 G71.00 G71.01 G71.02 G71.09 G81.90 G81.91 G81.92 G81.93 G81.94 H53.9 I05.0 I05.1 I05.2 I05.8 I05.9 I07.0 I07.1 I07.2 I07.8 I07.9 I08.0 I08.1 I08.2 I08.3 I08.8 I08.9 I09.0

Secondary malignant neoplasm of mediastinum Secondary malignant neoplasm of other specified sites Benign neoplasm of heart Alpha thalassemia Beta thalassemia Other thalassemias Thalassemia, unspecified Sickle-cell disease without crisis Sickle-cell thalassemia without crisis Sarcoidosis of lung Sarcoid myocarditis Sarcoidosis of other sites Sarcoidosis, unspecified Hemochromatosis, unspecified Other hemochromatosis Hemochromatosis, unspecified Organ-limited amyloidosis Amyloidosis, unspecified Muscular dystrophy, unspecified Duchenne or Becker muscular dystrophy Facioscapulohumeral muscular dystrophy Other specified muscular dystrophies Hemiplegia, unspecified affecting unspecified side Hemiplegia, unspecified affecting right dominant side Hemiplegia, unspecified affecting left dominant side Hemiplegia, unspecified affecting right nondominant side Hemiplegia, unspecified affecting left nondominant side Unspecified visual disturbance Rheumatic mitral stenosis Rheumatic mitral insufficiency Rheumatic mitral stenosis with insufficiency Other rheumatic mitral valve diseases Rheumatic mitral valve disease, unspecified Rheumatic tricuspid stenosis Rheumatic tricuspid insufficiency Rheumatic tricuspid stenosis and insufficiency Other rheumatic tricuspid valve diseases Rheumatic tricuspid valve disease, unspecified Rheumatic disorders of both mitral and aortic valves Rheumatic disorders of both mitral and tricuspid valves Rheumatic disorders of both aortic and tricuspid valves Combined rheumatic disorders of mitral, aortic and tricuspid valves Other rheumatic multiple valve diseases Rheumatic multiple valve disease, unspecified Rheumatic myocarditis

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I09.1 I10 I11.0 I11.9 I16.0 I16.1 I16.9 I20.0 I20.1 I20.8 I20.9 I21.01 I21.02

I21.09 I21.11 I21.19 I21.21 I21.29 I21.3 I21.4 I21.9 I21.A1 I21.A9 I24.0 I24.1 I24.8 I24.9 I25.10 I25.110 I25.111

I25.118 I25.119 I25.2 I25.3 I25.41 I25.5 I26.99 I27.0 I27.1 I27.20 I27.21 I27.22 I27.23

Rheumatic diseases of endocardium, valve unspecified Essential (primary) hypertension Hypertensive heart disease with heart failure Hypertensive heart disease without heart failure Hypertensive urgency Hypertensive emergency Hypertensive crisis, unspecified Unstable angina Angina pectoris with documented spasm Other forms of angina pectoris Angina pectoris, unspecified ST elevation (STEMI) myocardial infarction involving left main coronary artery ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall ST elevation (STEMI) myocardial infarction involving right coronary artery ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery ST elevation (STEMI) myocardial infarction involving other sites ST elevation (STEMI) myocardial infarction of unspecified site Non-ST elevation (NSTEMI) myocardial infarction Acute myocardial infarction, unspecified Myocardial infarction type 2 Other myocardial infarction type Acute coronary thrombosis not resulting in myocardial infarction Dressler's syndrome Other forms of acute ischemic heart disease Acute ischemic heart disease, unspecified Atherosclerotic heart disease of native coronary artery without angina pectoris Atherosclerotic heart disease of native coronary artery with unstable angina pectoris Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris Old myocardial infarction Aneurysm of heart Coronary artery aneurysm Ischemic cardiomyopathy Other pulmonary embolism without acute cor pulmonale Primary pulmonary hypertension Kyphoscoliotic heart disease Pulmonary hypertension, unspecified Secondary pulmonary arterial hypertension Pulmonary hypertension due to left heart disease Pulmonary hypertension due to lung diseases and hypoxia

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