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Q:

Oxford and Aetna Healthcare consistently denies CPT 78480 as inclusive to CPT 78465 or as not payable to a cardiologist. I believe the denial is incorrect and that the procedure should be payable. How do I proceed with getting reimbursed under my initial code?

A:

We have had the same issue with some of our cardiology clients. Based on feedback from our clients, Aetna does appear to be using bundling software that does not match CPT descriptions or the Medicare's National Correct Coding Initiative (CCI). When a physician bills:

(CPT 78465), "Myocardial perfusion imaging, tomographic (SPECT), multiple studies, at rest and/or stress (exercise and/or pharmacologic) and redistribution and/or rest ejection, with or without quantification.
We checked the Medicare Correct Coding Initiative ("CCI) Bundling Rule for comparison to determine if this was a proper denial of this CPT code. The CCI updates from the third quarter of 2001 through the third quarter of 2002 do not list CPT 78480 as a component of 78465. As many health plans have begun using Medicare as a basis for determining bundling rules, these disallows for the CPT code 78480 should be challenged with the argument that the health plan's edits do not conform to CPT or CMS standards. The request for reconsideration should also include a request for both the plans' policy and their rationale on payment of such myocardial imaging services.

In addition, a quick check of the website for the Local Medical Review Policies for Cardiology Nuclear studies for the New York Part B Carrier, Empire BC/BS, also shows the instructions that CPT 78480 may be used with the codes listed above. As an "add on" code, 78480 is billed without a -51 modifier. We also suggest referral of this problem to your State medical association and the AMA to as an example to utilize in their legal efforts to make health plans conform to accepted claim coding and bundling efforts.

 

Karen M. Beard, CPC (bio...)
Senior Associate

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