ASNC MODEL COVERAGE POLICY ASNC Model Coverage Policy: Single photon myocardial perfusion imaging David G. Wolinsky, MD,a Dennis A. Calnon, MD,b Christopher L. Hansen, MD,c Wael Jaber, MD,d Howard C. Lewin, MD,e Denise Merlino, CNMT,f Jeffrey A. Rosenblatt, MD,g Senthil Sundaram, MD,h Mark I. Travin, MD,i and Andrew Van Tosh, MDj study in the provided scenarios. Finally, we have pro- See related editorial, doi:10.1007/ vided the ICD-9 codes which correlate to each of the s12350-011-9416-6. indications to demonstrate what codes, or ranges of codes, are appropriate for each clinical indication. ENDORSING ORGANIZATIONS Purpose of Policy This document has been endorsed by the American College of Cardiology, American College of Radiology, The purpose and intent of this policy is to stream- and The Society of Nuclear Medicine. line the process by which payers reimburse for SPECT MPI procedures. It is our hope that by providing this list INTRODUCTION of clinical indications where a use of MPI is supported by our expert panel of reviewing cardiologists as well as Description of Policy our multi-society appropriate use criteria, and numerous literary references which demonstrate the value of the This document is intended as a model coverage study in a given scenario; that payers will accept and policy for SPECT myocardial perfusion imaging (MPI) adopt this model coverage policy as their own and use it studies and delineates under what clinical indications as a guide for reimbursing MPI studies. The hope is that such a study is appropriate to administer to patients. This this policy will serve as both an educational tool to document examines a variety of clinical indications and ASNC members and the cardiology community as a symptoms that a common patient would present with and whole, regarding both the appropriate use of SPECT supports the use of performing such a study by cross- MPI studies as well as demonstrate the correct ICD-9 referencing the indication with the multi-society appro- codes for those clinical indications. We also believe this priate use criteria for radionuclide studies developed by policy will serve as a literature-based guide for payers the American College of Cardiology (ACC)/ASNC in on how these clinical indications and ICD-9 codes 1 2005, and subsequently revised in 2009. In addition, the crosswalk to the SPECT MPI Appropriate Use Criteria. use of SPECT MPI in patients with the indications delineated in the policy is supported by references to an Policy Disclaimers abundance of literature which supports the use of this While ASNC strongly believes this model coverage policy for SPECT MPI is an excellent guide for clini- a From the Prime Care Physicians/Albany Associates in Cardiology, cians and payers alike, it should not be used as a Albany, NY; MidOhio Cardiology and Vascular Consultants,b Columbus, OH; Jefferson Heart Institute,c Philadelphia, PA; The comprehensive tool. We fully expect that as technolo- Cleveland Clinic Foundation,d Cleveland, OH; Cardiac Imaging gies and best practices in our medical field change and Associates,e Los Angeles, CA; Merlino Healthcare Consulting evolve, so too will this model coverage policy. In Corp,f Stoneham, MA; Maine Cardiology Associates,g South Port- addition, ASNC believes clinical decision-making h land, ME; Raleigh Cardiology Associates, PA, Raleigh, NC; regarding the appropriate application of SPECT MPI for Montefiore Medical Center,i New York, NY; and Beth Israel Med- ical Center,j New York, NY. a given patient should remain solely with the physician Reprint requests: David G. Wolinsky, MD, Prime Care Physicians/ treating the patient and should be first and foremost, Albany Associates in Cardiology, Albany, NY; dwolinsk@gmail. based on the ACCF/ASNC Appropriate Use Criteria. It com. is our position that in all cases where patients present J Nucl Cardiol with indications that fall under either the ‘‘A’’ (appro- 1071-3581/$34.00 Copyright Ó 2011 American Society of Nuclear Cardiology. priate) or ‘‘U’’ (uncertain) categories of the Appropriate doi:10.1007/s12350-011-9395-7 Use Criteria, these studies should be universally covered Wolinsky et al Journal of Nuclear Cardiology Single photon myocardial perfusion imaging and reimbursed by Medicare contractors and private §4317(b), of the Balanced Budget Act (BBA), payers. Typically, only studies which fall into the ‘‘I’’ specifies that referring physicians are required to provide (inappropriate) category should be denied reimburse- diagnostic information to the testing entity at the time ment.1 There may, however, be situations where a study the test is ordered. appears to fall into the ‘‘I’’ category initially, but upon 42 Code of Federal Regulations (CFR) §410.32 and further review or a peer-to-peer discussion with the §410.33, indicate that diagnostic tests are payable only insurer or their RBM about the provider’s rationale for when ordered by the physician who is treating the performing the study, it becomes apparent that the study beneficiary for a specific medical problem and who uses is not inappropriate and should in fact be covered by the the results in such treatment. insurer. In addition, we acknowledge that the informa- CMS Publication 100-04, Medicare Claims Pro- tion provided in this document is focused on the typical cessing Manual Chapter 4 patient’s clinical indications and there will always be – 200.8—Billing for Nuclear Medicine Procedures patients who present with indications or symptoms not captured within this model coverage policy. In those CMS Publication 100-04, Medicare Claims Pro- cases, it is our expectation that providers will adhere to cessing Manual Chapter 12 literature-based guidelines and provide the payer with as – 20.4.4—Supplies much clinical information as possible to support the use of performing a SPECT MPI study in an atypical patient. CMS Publication 100-04, Medicare Claims Pro- cessing Manual Chapter 13 Revision History – 20—Payment Conditions for Radiology Services The ASNC Model Coverage Policy for Myocardial – 50—Nuclear Medicine Perfusion Imaging was originally developed in 2005 and was revised in 2011. The impetus for revision of this CMS Publication 100-02, Medicare Benefit Policy model coverage policy is a result of a variety of coding Manual Chapter 15 and utilization modifications which have taken place – 60—Services and Supplies over the past few years and directly impact the practice – 60.1—Incident To Physician’s Professional Services of nuclear cardiology. In 2010, CPT implemented new – 80—Requirements for Diagnostic X-ray, Diagnostic packaged/bundled codes. These new bundled codes are Laboratory, and Other Diagnostic Tests represented by CPT codes 78451-78454. In addition, – 80.6—Requirements for Ordering and Following the ACCF/ASNC Appropriate Use Criteria for Cardiac Orders for Diagnostic Tests Radionuclide Imaging, which was published in 2005, was recently revised in 2009.1 Therefore, we felt it essential to update the policy to reflect modifications to INDICATIONS AND LIMITATIONS OF the Appropriate Use Criteria, which are based on expert COVERAGE AND/OR MEDICAL NECESSITY clinical judgment and expertise. In addition, ICD-9 codes are also updated annually and any change from MPI is a technique in which radionuclide tracers those annual updates are included in this revised policy. (predominantly thallium-201 and technetium 99m-based agents) are used to evaluate myocardial blood flow, as well as myocardial scarring or infarction, in order to AMA CPT/ADA CDT diagnose and assess the significance of coronary artery CPT codes, descriptions and other data only are disease (CAD). When administered intravenously, these copyright 2011 American Medical Association (or such radionuclides distribute in proportion to the regional other date of publication of CPT)/All Rights Reserved. myocardial blood flow present at the time of injection. Applicable FARS/DFARS Clauses Apply. MPI may be performed at rest, or more commonly, in conjunction with cardiac stress using exercise and/or pharmacologic stimulation (adenosine, regadenoson, CMS National dipyridamole or dobutamine). Technetium 99m-based Title XVIII of the Social Security Act, Sec- tracers are usually administered twice, once at rest, and tion 1862(a)(1)(A) allows coverage and payment for again following cardiac stress. Thallium-201 is usually only those services that are considered to be medically administered following cardiac stress, with a booster dose reasonable and necessary. Title XVIII of the Social sometimes being given prior to rest imaging. The tracer Security Act, Section 1833(e) prohibits Medicare pay- distribution in the heart is then imaged using a gamma ment for any claim, which lacks the necessary camera, yielding scintigrams which depict the myocardial information to process the claim. distribution of coronary blood flow. Typically, the Journal of Nuclear Cardiology Wolinsky et al Single photon myocardial perfusion imaging scintigrams are compared qualitatively and/or quantita- (1) Diagnosis In patients suspected of having coronary tively to recognized normal patterns. Perfusion disease because of chest discomfort, dyspnea, abnormalities, or defects, are assessed and quantified as to arrhythmias, cardiac risk factors or other clinical location, extent and severity, often allowing localization findings, stress MPI is a highly sensitive and specific to specific coronary artery territories. Perfusion defects test for identifying CAD. In patients presenting to present with cardiac stress and absent at rest are termed the emergency department with acute chest pain, ‘‘reversible’’, and are suggestive of myocardial ischemia, rest MPI is effective in diagnosing an acute coronary and hemodynamically significant coronary stenoses. syndrome (Table 1). Defects present on both rest and stress imaging are con- (2) Prognosis In patients with known or suspected sistent with myocardial scarring or infarction. MPI is most CAD, the extent of myocardial ischemia, infarction, often performed using tomographic techniques and and viability determined by MPI correlate well with reconstruction algorithms utilizing either filtered back prognosis.