Does 78494 require prior authorization?

Yes, 78494 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 78494?

Medicare facility rate: $12.54. Non-facility rate: $12.54. Work RVU: 1.16.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

1.16

Facility

$12.54

Non-Facility

$12.54

Use CPT codes 78472, 78473, 78481, 78483, 78494, or 78496 when billing cardiac blood pool imaging (MUGA, ventriculography).
When applicable, include the additional secondary code indicating personal history of malignant neoplasm (Z85 series) per Correct Coding Initiative (CCI) guidelines alongside the appropriate C-code or D-code family entry.
Refer to the policy's Covered ICD-10 Codes section to select the appropriate C-code, D-code, and Z85 family codes for billing cardiac blood pool imaging.
Claims for stress tests performed as preoperative evaluation of asymptomatic, moderate-risk patients must include medical record documentation of at least one of: diabetes mellitus with complications; peripheral vascular disease; aortic aneurysm; or cerebrovascular disease.

Cardiac blood pool imaging (MUGA, ventriculography) is covered when performed for patients receiving cardiotoxic chemotherapy.
Cardiac blood pool imaging is covered for evaluation of valvular disease or cardiomyopathies.
Prior to initiation of cardiotoxic chemotherapy, bill cardiac blood pool imaging with ICD-10 code Z01.89 plus the appropriate C-code or D-code family entry.
During or for interval assessment while receiving cardiotoxic chemotherapy, bill using the appropriate T45.1X5* encounter code (T45.1X5A, T45.1X5D, or T45.1X5S) to indicate ongoing exposure.
At completion of cardiotoxic chemotherapy, bill cardiac blood pool imaging with ICD-10 code Z08 and the appropriate C-code or D-code family entry.
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.

A56743 — Billing and Coding: Cardiovascular Nuclear Medicine

J06

L33560 — Cardiovascular Nuclear Medicine

J06

L33693 — Peripheral Venous Ultrasound

J09

L37371 — Electroretinography (ERG)

J12

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

Ask Verity about documentation requirements, denial risks, or coverage in your state.