Question:

I am still confused about the changes to the cardiac positron emission tomography (PET) codes made in 2020. Can you help me understand them better?

Answer:

The existing codes such as 78459, 78491, and 78492 now specifically state that they include ventricular wall motion and/or ejection fraction if performed. If you don’t perform wall motion or ejection fraction, you do not need to add modifier 52, but you also can’t add another code if you do perform these. In addition, 78459, the metabolic exam (often called a viability exam) is now noted to be a single study. If performed with a concurrently acquired computed tomography (CT) scan for attenuation correction and anatomic localization, you would report code 78429 instead of 78459. This CT is not a diagnostic CT, if a full diagnostic CT scan is performed, report the appropriate cardiac CT code. The existing myocardial perfusion PET codes (78491, 78492) remain with the addition as noted above that they include wall motion and/or ejection fraction when performed. New codes were added to include exams performed with CT for attenuation correction and anatomic localization. All four of these codes now also specify that the stress test portion may be exercise or pharmacologic stress. Code 78491 remains a single study, either rest or stress. Code 78430 is a single study, either rest or stress with the addition of concurrently acquired CT for attenuation correction and anatomic localization.

Code 78492 includes multiple studies at rest and stress, while 78431 includes multiple studies at rest and stress with a concurrently acquired CT for attenuation correction and anatomic localization. Combination viability and perfusion PET scans are now often performed and prior to 2020 separate codes were assigned. There are now combination codes for these procedures. Code 78432 is a PET that combines a metabolic study with a perfusion study. Two separate radiopharmaceuticals are used for these exams, FDG for the metabolic scan, and either Rubidium or Ammonia N-13 for the perfusion scan. Code 78433 is the same as code 78432 with the addition of a concurrently acquired CT for attenuation correction and anatomic localization With these codes, “concurrently acquired CT” means a CT performed on the same equipment and not one acquired on a separate system with software fusion used to perform the anatomic localization. If you do not have the hybrid system that performs both, the imaging fusion would be reported with unlisted code 78499. Also, Category III code 0482T transitioned to Category I code 78434. This add-on code may be reported along with code 78431 or 78492 when absolute quantitation of myocardial blood flow is obtained.

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