(2023) CPT Code 78452 | Description, Guidelines, Reimbursement, Modifiers & Examples

CPT code 78452 is used to bill for 3D (three-dimensional) imaging of the heart by using a high-energy CT (Computed tomographic) scanner (SPECT).

A radioactive substance is incorporated by mouth or IV (Intravenous) to focus the heart function and blood flow by taking images. Radionucleotides, usually thallium or technetium-99m, are localized only in non-ischemic tissue.

These substances are injected through an IV route to the body of the patient to perform tomographic Cardiac perfusion imaging. SPECT (Single-photon emission computed Tomographic) scans of the heart are obtained to classify areas of perfusion vs. infarction.

SPECT usually has a single or multiple head camera that can easily rotate around the patient’s body which differs from typical planar imaging.

It gives a 3D scan of the heart to represent the heart in thin slices. When service is performed without stress, induction and images are obtained, known as the non-stress version. 

Summary

For multiple studies, CPT code 78452 will be billed that take images at rest or stress conditions by giving the second radionucleotide again in the redistribution and/or resting phase just before rest state to scan the rest imaging.

CPT 78451 and CPT code 78452 include attenuation correction (AC), which helps to obtain the most accurate diagnostic imaging for diagnosing defects or infarcted areas by enhancing the radioactivity distribution count at that particular area. 

For example, If radioactivity count is lower at the anterior wall due to the presence of breast.

These codes also include ejection fraction (EF) quantitative and qualitative wall motion to cater to this problem by additional quantification and/or the first pass or gated technique.

Description

When multiple studies are performed at rest and/or stress (exercise or pharmacologic), and/or rest injection and/or redistribution to perform 3D SPECT Myocardial perfusion imaging which also includes:

• Ejection fraction by gated technique or first pass
• Attenuation correction
• Additional quantification
• Qualitative and quantitative wall motion

Modifiers

The most frequent modifiers used with CPT 78452 are 22, 26, 52, 53, and TC.

Modifier 26 is applicable with CPT code 78452 when a physician is only giving professional services like in a hospital as an employee. The physician is doing supervision and interpretation of medical imaging.

Modifier TC (Technical component) is appropriate to bill with facility claims. It designates the technical component used during medical imaging.

A global modifier is used when Physicians own the clinic or do services in a private office. The physician owns the Machinery or technical component.

In this scenario, a global modifier will be used, which means that without modifiers 26 and TC. It would be like 78452 only instead of 78452-26, 78452-TC.

Modifier 52 is applicable when the service is partially complete or reduced services. The CPT code 78452 scenario includes 3D imaging at rest and/or stress state.

The second radionucleotide was not given due to unavoidable circumstances like electricity issues or the patient’s condition. In this case, Modifier 52 will be attached with CPT 78452. 

Modifier 53 is applicable with CPT 78452 when the procedure is terminated due to the patient’s conditions or other unavoidable circumstances.

For instance, When a physician starts the procedure or service, an IV radionuclide is injected into the patent’s body, and any allergic reaction starts against the substance. Patients’ conditions become critical, and they decide to terminate the procedure early. 

Modifier 22 will be appended with CPT code 78452 when services get longer than normal. 

Reimbursement

CPT 78452 rate varies based on what modifier is attached, like Modifier 26, TC, or global Modifier. Only 1 unit can be billed for CPT 78452 on the same day.

Two units are allowed if medical documentation supports this service. The total RUVS and cost of CPT code 78452 are listed in the list below:

Facility – 15.5 (Global) – 2.40 (Modifier 26) – 13.0 (TC)

Non-Facility – 15.5 (Global) – 2.40 (Modifier 26) – 13.0 (TC)

Facility – 536.40$ (Global) – 83.36$ (Modifier 26) – 453.04$ (TC)

Non-Facility – 536.40$ (Global) – 83.36$ (Modifier 26) – 453.04$ (TC)

OPPS Global – 1647.65$ (Global) – 83.36$ (Modifier 26) – 1564.29$ (TC)

Billing Guidelines

There are the following guidelines for CPT 78452:

Stress test CPT codes (93015-93018) should also be reported separately in combination with CPT 78452.

Any substance or contrast media injected during studies will be billed separately with HCPCS Level II Codes, which may be reported with A9501-A9502, A9505, A9526, A9526, A9538, and A9560.

Some Payers or insurance does not cover the substance or contrast media. Therefore, Check with a specific payer to determine the coverage.

 CPT 78451 and CPT code 78452 are not allowed to be billed together on the same day as per the National Correct Coding Initiative (NCCI), and the modifier is also not allowed.

Therefore, Only 1 CPT will be payable, usually with the higher amount, which is CPT 78452.

CPT 785452 does not include CPT Codes (78800 – 78804) and (78830 -78835), which should be separately reportable with the appropriate modifier.

A modifier is allowed to append with CPT (78800 – 78804) (78830 – 78835) as per NCCI. 

In order to receive proper reimbursement, the ICD 10 codes play a significant role in the reimbursement of CPT codes.

CPT code 78452 only gets paid when heart-related ICD 10 codes are attached with claims according to their respective LCD/NCD.

The most common ICD codes that support the medical necessity of CPT Codes are I25.10, RO7.9, R06.02, and if the patient has a family history of heart disease should also be appropriate to code.

Examples 

The following are examples of when it is appropriate to use CPT Code 78452:

Example 1

The patient is a fifty-five-year-old male presenting with chest pain. Cardiac risk factors include age, male gender, hyperlipidemia, class 1 obesity, diabetes.

She had taken some medication for pain control. Issues did not get resolved.

He reports that pain has become severe since the last 2 to 3 days and is not bearable. She also reports some change in hearing in her right ear.

The patient denies fevers, chills, headaches, changes in vision, throat pain, dysuria, nausea and vomiting, lightheadedness, or dizziness.

The physical exam was done by a physician, and they decided to do a Diagnostic study, MRI, and MRA of the chest and cardiac profile studies.

Example 2 

Female, 68 years of age, with multiple cardiac risk factors presenting with chest pain.

Cardiac risk factors include age; coronary artery disease s/p STEMI and stenting; hypertension; hyperlipidemia; Patient had a family history of heart disease and may require open-heart surgery.

Pt denies any redness, swelling, discharge. She is not currently on ABX. Pt denies f/c, Abdominal pain, cough, headache, dysuria.

The physician had done a Cardiac Imaging study disease which revealed that the patient has an atherosclerosis disease of the heart. 

Example 3

Male, 67 years of age, with a history of atrial fibrillation and multiple cardiac risk factors presenting with shortness of breath, weakness, chest pain responsive to nitroglycerin. Cardiac risk factors

include age; male gender; coronary artery disease s/p CABG and stenting; hypertension; hyperlipidemia; class 1 obesity; type II diabetes.

Nausea and vomiting in the context of hyperglycemia. Pt stated 1.5 weeks ago. He began having generalized weakness and pain in his entire body. Starting two days ago, after eating lunch, he began having nausea and vomiting and has not been able to keep down food since.

He also reports shortness of breath worse with movement and lightheadedness on ambulation.

He denies fevers, chills, rashes, abdominal pain, dysuria, headache, tingling, recent travel, sick contacts. He is not covid vaccinated.

The study revealed that patient has higher risks of heart disease. Physicians order Cardiac imaging, Labs, MRI to diagnose heart disease.

Example 4

Male, 50 years of age, presenting with shortness of breath, elevated troponin, chest pain responsive to nitroglycerin.

Cardiac risk factors include age, male gender, hypertension, hyperlipidemia, overweight.

History of uterine cancer status post-surgery remotely here with right-sided weakness and swelling for two days. No, cough, vomiting, fever, or chills. They are taking pain killer for pain relief.

The patient is well-appearing and stable with an exam. Only remarkable for mild erythema and swelling. Physicians ordered Cardiac perfusion imaging to diagnose heart-related disease.

Example 5

Eighty-three years of age, with a history of atrial fibrillation and multiple cardiac risk factors presenting with shortness of breath and chest pain.

Cardiac risk factors include advanced age; coronary artery disease s/p stenting; hypertension; hyperlipidemia; remote smoking.

Son reports that he became febrile yesterday evening highest temp of 101 gave Tylenol with the resolution of fever.

Other reports that he had nausea, vomiting, and cough. The cough is not productive.

Son states that father has been eating, drinking, urinating, defecating with no issues. He is overall talkative and has no changes in behavior.

Physicians ordered multiple diagnostics tests CT Chest, X-ray of the chest, Labs, and CT perfusion imaging of cardiac. 

By Uzair Ali Murtaza
Expert Medical Coding & Billing