78430: Myocardial perfusion PET/CT with single study (rest OR stress only). Used when only one phase of imaging is performed.

78431: Multiple studies (both rest AND stress). This is the most commonly used code for complete cardiac PET/CT evaluation.

78434: Add-on code for Absolute quantification of myocardial blood flow. Always billed with 78430 or 78431.

Clinical Example: Complete rest/stress cardiac PET/CT = 78431 + 78434

No. The CT attenuation correction and anatomical localization is bundled into CPT 78433, which is an add-on code to 78431 or 78432.

You cannot separately bill for:

• CT professional component (26 modifier)
• CT technical component (TC modifier)
• Separate CT CPT codes (71250, 71260, etc.)

Exception: If a diagnostic CT with contrast is performed for clinical evaluation separate from the PET study, it may be separately billable with appropriate documentation.

Use the CMS Physician Fee Schedule Look-Up Tool at: https://www.cms.gov/medicare/physician-fee-schedule/search

Steps:

1. Select your MAC (Medicare Administrative Contractor) region
2. Enter CPT code (e.g., 78431)
3. Select your facility type (office, hospital outpatient, etc.)
4. View both professional (26) and technical (TC) component rates

Important: Rates are adjusted annually and vary by geographic locality.

Common Modifiers:

• 26 (Professional Component): For physician interpretation only
• TC (Technical Component): For facility/equipment charges only
• 59 (Distinct Procedural Service): When billing multiple imaging studies same day
• 76 (Repeat Procedure): If study repeated same day by same physician
• 77 (Repeat Procedure by Another Physician): If different physician repeats study
• JZ (Zero Drug Waste): Required for single-dose vial medications with no waste

Billing Examples:

• Physician office (owns equipment): Bill global codes without modifiers
• Hospital outpatient: Physician bills 78431-26, hospital bills 78431-TC

Billing Units: Bill 2 units per complete rest/stress study (one dose for rest, one dose for stress)

Important Notes:

• A9555 must be billed on the same claim as the CPT procedure code
• Separate billing may result in denial or payment delays
• Medicare payment varies by MAC and date of service
• Some commercial payers require separate prior authorization for radiopharmaceuticals

Example Claim:

• Line 1: CPT 78431 (rest and stress PET)
• Line 2: CPT 78434 (add-on for myocardial blood flow)
• Line 3: A9555 x 2 units (Rubidium doses)
• Line 4: J2785 x 4 units (Regadenoson 0.4mg)

CPT 78434: Absolute quantification of myocardial blood flow (MBF)

Clinical Use: Add-on code for quantitative flow analysis providing absolute measurements in ml/min/gram of tissue

Requirements:

• Must be billed with 78430 or 78431
• Requires appropriate software and training
• Documentation must show quantitative flow values in report
• Medical necessity must be established

Medicare Coverage: Check MAC-specific LCDs - coverage varies by region

Average Reimbursement: $425.00 (Medicare national average)

Most major commercial payers require PA:

• UnitedHealthcare: Requires eviCore/Optum PA
• Anthem/Blue Cross Blue Shield: Requires AIM Specialty Health PA
• Cigna: Requires PA through internal review
• Aetna: Requires PA for CPT 78430, 78431, 78434, 78491, 78492
• Humana: PA requirements vary by plan

Best Practice: Always verify PA requirements before scheduling - requirements change frequently

A3i Health Advantage: Our team maintains current PA requirements for 800+ payer-plan combinations and obtains authorizations with under 4-day average turnaround

Generally NO - Traditional Medicare (Fee-for-Service) typically does not require prior authorization for cardiac PET/CT

Exceptions:

• Some MACs have specific Local Coverage Determinations (LCDs) requiring documentation of medical necessity
• Certain experimental or investigational indications may not be covered
• Prior authorization may be required through CERT audits or Targeted Probe and Educate (TPE) programs

Medicare Advantage Plans: DO require prior authorization in most cases (treat as commercial payers)

Required Information:

• Patient Demographics: Name, DOB, insurance ID, policy/group numbers
• Clinical Indication: Specific symptoms (chest pain, dyspnea, etc.)
• Diagnosis Codes: ICD-10 codes supporting medical necessity
• Prior Testing: Results of ECG, stress test, echo, or other cardiac testing
• Risk Factors: CAD risk factors (diabetes, hypertension, family history, smoking, etc.)
• Procedure Details: CPT codes, planned radiopharmaceutical, facility information
• Ordering Physician: NPI, specialty, office contact information

Timeline: Submit PA requests 7-10 business days before scheduled procedure to allow processing time

Industry Standards:

• Routine requests: 7-14 business days
• Expedited/Urgent: 72 hours (if criteria met)
• Pre-Determination: May add 7-10 additional days (if offerred by payer)
• Peer-to-peer review: May add 3-5 additional days

A3i Health Performance:

• Average turnaround: under 4 days
• Success rate: 98% approval on initial submission
• Process: Automated tracking, proactive payer communication, clinical documentation support

State Laws: Many states have PA turnaround time mandates (typically 72 hours urgent, 7-14 days routine)

Appeal Steps:

1. Review Denial Reason: Obtain detailed explanation from payer
2. Gather Additional Documentation: Supplement clinical information, add supporting studies
3. Request Peer-to-Peer: Physician-to-physician discussion often reverses denials
4. File Level 1 Appeal: Submit within timeline (typically 60 days)
5. Escalate if Needed: Level 2 appeals, state insurance department complaints, independent medical review

Common Denial Reasons:

• Insufficient documentation of medical necessity
• Prior testing not completed (stress test, echo, etc.)
• Incorrect procedure codes
• Out-of-network facility issues

A3i Support: Our team handles appeals, peer-to-peer coordination, and documentation support

Essential Documentation Elements:

• Chief Complaint: Specific symptoms (chest pain type/location/duration, dyspnea, fatigue, etc.)
• Medical History: CAD risk factors, prior cardiac events, family history
• Physical Examination: Relevant cardiovascular findings
• Prior Testing: Results and limitations of previous studies (ECG, stress test, echo, cath)
• Clinical Decision Making: Why PET/CT is appropriate for this patient
• Treatment Plan: How results will impact management

Documentation Must Be:

• Signed and dated by ordering physician
• Available before procedure
• Consistent across office notes, PA requests, and medical records

Required Report Elements:

• Clinical Indication: Reason for study
• Radiopharmaceutical: Agent, dose, route, time of administration
• Stress Protocol: Type (exercise/pharmacologic), agent, dose, patient response
• Image Quality: Technical adequacy, motion artifacts, attenuation issues
• Findings: Perfusion abnormalities (location, severity, extent), viability assessment if performed
• Quantitative Data: If CPT 78434 billed, must include absolute flow values
• CT Findings: Coronary calcium score if calculated, incidental findings
• Comparison: To prior studies if available
• Impression: Clear summary with clinical recommendations

Sign-off: Report must be finalized, signed, and dated by interpreting physician within 48-72 hours

CAC Documentation:

• Agatston Score: Total score and percentile for age/sex/ethnicity
• Vessel-Specific Scores: Individual scores for LAD, LCX, RCA
• Clinical Interpretation: Risk category (minimal, mild, moderate, severe)

Billing Consideration: CAC scoring performed as part of cardiac PET/CT is typically bundled into the CT component (78433) and not separately billable unless performed as distinct study

Separate CAC Study: CPT 75571 can be billed separately only if:

• Performed on different date from PET/CT
• Medical necessity documented separately
• Clear clinical indication distinct from PET referral

Required Accreditation (choose one):

• IAC (Intersocietal Accreditation Commission) - Nuclear/PET accreditation
• ACR (American College of Radiology) - Nuclear Medicine accreditation
• RadSite - Advanced diagnostic imaging accreditation

Accreditation Covers:

• Equipment quality assurance
• Qualified personnel (technologists, interpreting physicians)
• Safety protocols
• Image quality standards
• Record keeping

Compliance: Medicare and most commercial payers require current accreditation. Must be renewed typically every 3 years

Documentation: Accreditation certificate must be available for payer audits

Board Certification:

• ABNM (American Board of Nuclear Medicine)
• ABR with Nuclear Radiology certification
• ABIM with Cardiovascular Disease + Nuclear Cardiology certification

Training Requirements:

• Completion of approved nuclear cardiology training program OR
• 500+ hours of documented training in nuclear cardiology OR
• Interpretation of 300+ nuclear cardiology studies

Continuing Education: Maintain required CME in nuclear cardiology/PET imaging

Medicare Requirements: Must be enrolled in Medicare with correct specialty designation

MQSA (Mammography Quality Standards Act) is specific to mammography and does NOT apply to cardiac PET/CT

Applicable Regulations:

• FDA: PET scanner registration and quality control
• State Radiation Control: Licensing and inspection requirements vary by state
• ACR/IAC Standards: Voluntary but required for accreditation and Medicare billing
• NRC/Agreement State: Radioactive material licensing (if applicable based on generator type)

Payment Timelines:

• Medicare: 14-30 days for clean claims
• Commercial Payers: 30-45 days (many state laws require payment within 30 days)
• Medicare Advantage: 30-60 days

Factors Affecting Timeline:

• Electronic vs. paper claim submission
• Complete vs. incomplete documentation
• Prior authorization on file
• Payer-specific processing procedures

Expediting Payment:

• Submit claims electronically
• Include all required documentation
• Reference PA number if applicable
• Follow up on unpaid claims after 30 days

Yes - Mobile PET/CT is allowed with proper compliance

Requirements:

• Medicare Enrollment: Mobile unit must be enrolled separately (CMS-855I)
• Each Service Location: Report each site where mobile unit operates
• Accreditation: Mobile unit must maintain same accreditation as fixed facility
• State Licensing: Comply with all state requirements for mobile imaging
• Medical Direction: Supervising physician must be present or immediately available

Billing: Use place of service code 21 (Inpatient Hospital) or 22 (Outpatient Hospital) based on where mobile unit is located during service