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All cardiac PET codes, including combination codes, now include wall motion (WM) and ejection fraction (EF)

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Q.

Some time in 2020, the American Medical Association (AMA) decided to discontinue allowing the wall motion (WM) and ejection fraction (EF) being additionally, separately charged with a cardiac PET. They (WM and EF) are both now bundled with CPT® codes 78431 (multiple) and 78430 (single) PET charges? Do you know when that change exactly took place? 

I have numerous questions related to this. Was it in January 2020?  If so, do we need to adjust charges to reflect this? We have been told it can be up to a two-year lag for reimbursement due to claims data needing to catch up….is that correct? 

When considering that bundled fee, (to include charging for the WM and EF with the PET study) are we able to charge for either a single WM & EF or multiple WM & EF’s within that bundle?  Finally, when we perform a viability study with single or multiple perfusion images, do we also need to bundle in the WM and EF studies as well?

A.

Yes, WM and EF are now included by definition in all cardiac PET and PET/CT code options. These codes, the other new cardiac PET codes, and the definition changes to the existing codes became effective on 1/1/2020. The entire PET and PET/CT options for cardiac procedures by category include the following codes:

Metabolic Studies

78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study 

78429 Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan

Perfusion Studies-single study

78491 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic)

78430 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan

Perfusion Studies-multiple studies

78492 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic)

78431 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan

Combined Metabolic and Perfusion Studies

78432 Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability);

78433 Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan;

The hospital’s cost for the procedures defined by these codes needs to include the cost of WM and EF. Reimbursement updates are based on claims from two years past, but when new codes are being created, surveys are sent out by the relative specialty societies to their members to help gather information on the cost of the new codes (which would have often been coded with unlisted codes). That information is submitted to RUC and CMS, so, they try to start out with good claims data. If I am understanding your question regarding single or multiple WM/EF, if they normally do multiple WM & EF, then that should be considered when a fee is assigned to the procedure code. If they normally perform a single WM & EF calculation, then the cost of only one should be added into the cost for the scan. 

To restate, all of the cardiac PET codes, including the combination codes now specifically include WM and EF. This also includes the previously existing codes 78429, 78459, 78491, and 78492 as well.