78468
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.78
Facility
$16.75
Non-Facility
$16.75
Documentation Required
- The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit.
- The medical record must include relevant medical history and results of pertinent tests and procedures.
- Office visit records and operative reports must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.
- When using the -GA modifier and ABN, Form CMS-R-131 must be signed by the beneficiary (or properly witnessed if the beneficiary refuses to sign) to indicate acceptance of payment responsibility.
Key Coverage Criteria
- For services that require a referring or ordering physician, the claim must report the referring/ordering physician's name and NPI.
- Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed; otherwise the claim will be returned as incomplete under SSA Section 1833(e).
- For diagnostic tests, the claim should report the test result if known, otherwise report the symptoms that prompted the test.
- If a service is likely to be non-covered, an Advance Beneficiary Notice (ABN) may be used and the appropriate modifier (GA, GX, GY, or GZ) should be appended to the claim as applicable.
- Cardiovascular nuclear medicine testing is reimbursable for risk assessment or re-evaluation in asymptomatic patients or patients with stable symptoms who have known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, provided the patient has not undergone a revascularization procedure within the prior 2 years.
- Blood pool scan to assess left ventricular ejection fraction prior to implantation of an implantable cardioverter-defibrillator (ICD) or biventricular pacemaker is covered when the medical record documents the intended plan for device insertion and the test result.
14 Active Policies
L33560 — Cardiovascular Nuclear Medicine
J06
A56743 — Billing and Coding: Cardiovascular Nuclear Medicine
J06
L33693 — Peripheral Venous Ultrasound
J09
L35434 — Oximetry Services
J12
L35451 — Peripheral Venous Ultrasound
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.