A3i HEALTH
Prior Authorizations Simplified
Detailed Coding Reference
Comprehensive guide to cardiac PET/CT CPT codes, modifiers, and billing requirements
Primary Cardiac PET/CT Procedure Codes
| CPT Code | Description | Global | Professional (26) | Technical (TC) |
|---|---|---|---|---|
| 78430 | Myocardial perfusion imaging, positron emission tomography (PET), single study, rest or stress (exercise or pharmacologic) | $1,535.83 | $72.82 | $1,463.01 |
| 78431 | Myocardial perfusion imaging, positron emission tomography (PET), multiple studies, rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | $1,850.00 | $185.00 | $1,665.00 |
| 78434 | Add-on: Absolute quantification of myocardial blood flow | $425.00 | $85.00 | $340.00 |
Important Notes:
- CPT 78430: Use for single study only (rest OR stress, not both)
- CPT 78431: Use for multiple studies (rest AND stress)
- CPT 78434: Only when quantitative flow analysis performed and documented
- CPT 78491: Use for single study without CT
- CPT 78492: Use for multiple studies without CT
- Rates shown are Medicare national averages for 2025 - actual rates vary by locality
Alternative Myocardial PET Codes (Without CT)
| CPT Code | Description | Medicare Rate | Use Case |
|---|---|---|---|
| 78491 | Myocardial PET perfusion, single study rest OR stress (exercise or pharmacologic) | $1,533.33 | Rest OR stress only, no CT |
| 78492 | Myocardial PET perfusion, multiple studies (both rest AND stress) | $1,544.44 | Rest AND stress, no CT |
Note: These codes are used less frequently now that CT attenuation correction is standard practice
Radiopharmaceuticals (HCPCS A Codes)
| HCPCS Code | Agent Description | Unit Definition | Medicare Rate | Billing Notes |
|---|---|---|---|---|
| A9555 | Rubidium Rb-82, diagnostic | Per study dose, up to 60 mCi | $532.65 per dose or Contractor priced (each MAC set's its price) | Bill 2 units for rest/stress study |
Critical Billing Requirements:
- Same Claim Submission: Radiopharmaceuticals must be billed on the same claim as the procedure code
- Separate PA May Be Required: Some commercial payers require separate authorization for radiopharmaceuticals
- 2025 CMS Policy Change: Diagnostic radiopharmaceuticals with per-day cost >$630 now receive separate payment in HOPPS setting
- Unit Accuracy: Billing incorrect units is a leading cause of denials
Pharmacologic Stress Agents (HCPCS J Codes)
| HCPCS Code | Agent | Unit Definition | Standard Dose | Units to Bill | Medicare Rate |
|---|---|---|---|---|---|
| J2785 | Regadenoson (Lexiscan) | Per 0.1mg | 0.4mg | 4 units | $125.00 |
JZ Modifier Requirement:
Use modifier JZ to indicate zero drug amount discarded/not administered to any patient for single-use vials with no waste. Required by CMS for accurate drug pricing data.
Example: J2785 x 4 units, JZ (for standard 0.4mg regadenoson dose with no waste)
Essential CPT Modifiers for Cardiac PET/CT
| Modifier | Description | When to Use | Example |
|---|---|---|---|
| 26 | Professional Component | Physician interpretation only (no equipment ownership) | 78431-26 (reading only) |
| TC | Technical Component | Facility charges only (equipment, staff, supplies) | 78431-TC (hospital facility) |
| 59 | Distinct Procedural Service | Separate procedure performed same day | Cardiac PET + separate diagnostic CT |
| 76 | Repeat Procedure by Same Physician | Study repeated same day due to technical issues | 78431, 78431-76 |
| 77 | Repeat Procedure by Another Physician | Different physician repeats/reinterprets study | Second opinion reading |
| JZ | Zero Drug Amount Discarded | Single-dose vial with no waste | J2785 x 4, JZ |
| JW | Drug Amount Discarded | Document wasted drug from multi-dose vial | J2785 x 10, JW (if some discarded) |
Place of Service (POS) Codes
| POS Code | Setting | Billing Implications |
|---|---|---|
| 11 | Office | Physician office/clinic. Bill global codes (no modifiers unless split billing) |
| 22 | Outpatient Hospital | Hospital bills TC, physician bills 26. HOPPS payment system applies |
| 21 | Inpatient Hospital | Physician bills professional component only. Included in DRG for facility |
| 24 | Ambulatory Surgical Center | Limited cardiac PET performed in ASC. ASC payment system |
| 49 | Independent Clinic | IDTF or similar. MPFS payment for both components |
Common Supporting ICD-10 Diagnosis Codes
Medical necessity must be established through appropriate diagnosis codes. Common indications include:
Chest Pain Syndromes
- R07.9 - Chest pain, unspecified
- R07.2 - Precordial pain
- R07.89 - Other chest pain
- I20.0 - Unstable angina
- I20.8 - Other forms of angina pectoris
- I20.9 - Angina pectoris, unspecified
Coronary Artery Disease
- I25.10 - Atherosclerotic heart disease without angina
- I25.110 - CAD of native coronary artery with unstable angina
- I25.119 - CAD of native coronary artery with angina
- I25.700 - Atherosclerosis of coronary artery bypass graft
- Z95.1 - Presence of CABG
Heart Failure & Cardiomyopathy
- I50.9 - Heart failure, unspecified
- I50.21 - Acute systolic heart failure
- I50.23 - Acute on chronic systolic heart failure
- I42.0 - Dilated cardiomyopathy
- I42.9 - Cardiomyopathy, unspecified
Cardiac Symptoms
- R06.02 - Shortness of breath
- R53.83 - Other fatigue
- R00.2 - Palpitations
- R55 - Syncope and collapse
- R94.31 - Abnormal ECG
Risk Factors
- E11.9 - Type 2 diabetes without complications
- I10 - Essential hypertension
- E78.5 - Hyperlipidemia
- Z82.49 - Family history of CAD
- F17.210 - Nicotine dependence
Post-Procedural Evaluation
- Z95.5 - Presence of coronary angioplasty implant/stent
- Z95.810 - Presence of automatic implantable cardiac defibrillator
- Z95.0 - Presence of cardiac pacemaker
Important: List diagnosis codes is informational only. Physician is always responsible for diagnosis code selection. Primary diagnosis should be the main reason for the study. Include all relevant risk factors and comorbidities to support medical necessity.