78431
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
$68.05
Non-Facility
$68.05
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include complete patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- Every submitted medical record page must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- If the service provider differs from the ordering/referring physician, the performing provider must maintain hard copy documentation of test results and interpretation plus copies of the ordering/referring physician’s order for the studies.
Key Coverage Criteria
- Coverage for non-emergent outpatient stress testing is subject to the reasonable and necessary requirements in Local Coverage Determination L35083 and is allowed only when L35083 clinical criteria are met.
- Preoperative cardiac stress testing with radionuclide imaging for asymptomatic patients deemed at moderate risk is covered only if the medical record documents at least one of the following: diabetes mellitus with complications; peripheral vascular disease; aortic aneurysm; or cerebrovascular disease.
- CPT 78434 (gated SPECT) may be reported only in conjunction with CPT 78431 or CPT 78492 when billed for SPECT myocardial perfusion imaging (MPI).
- SPECT MPI includes routine evaluation of left ventricular wall motion and left ventricular ejection fraction (LVEF) as part of the MP1 service definition.
- An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
- Additional services and supplies (e.g., radiopharmaceuticals, special contrast agents, medications) are payable to an IDTF when the diagnostic test itself is payable and the supplies are commonly separately reimbursed to a physician in an office setting.
20 Active Policies
A56952 — Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing
J09
L38396 — Cardiology Non-emergent Outpatient Stress Testing
J09
L33693 — Peripheral Venous Ultrasound
J09
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L35007
Related Codes
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