01-161 CV Nuclear Testing Notification of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers of Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part B of A for cardiovascular nuclear testing services billed on dates of service January 1, 2024 through December 31, 2025. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
Background
Cardiovascular diagnostic services support early detection and management of cardiac conditions by guiding treatment and ongoing monitoring. Nuclear cardiology services including positron emission tomography (PET), single-photon emission computed tomography (SPECT) myocardial perfusion imaging, and planar myocardial perfusion imaging, use radioactive tracers to evaluate myocardial blood flow, cardiac function, and tissue viability. These diagnostic services are covered under Medicare Parts B and B of A when medical necessity and applicable coverage criteria are met.
Myocardial perfusion imaging (MPI) is a noninvasive nuclear medicine scan, using PET or SPECT technology, that creates images of blood flow to the heart muscle to detect blockages, ischemia, or scarring. The test compares images taken at rest and during stress, offering high accuracy for detecting coronary artery disease (CAD) and heart failure.
PET imaging offers superior spatial and temporal resolution compared to other modalities, allowing for more accurate quantification of perfusion and cardiac function. SPECT imaging is widely available and provides valuable diagnostic information. Though it generally offers lower resolution than PET, it remains a cornerstone in the noninvasive assessment of cardiac perfusion. While less commonly used than SPECT or PET, planar imaging can provide valuable diagnostic information in settings where tomographic imaging is unavailable or not indicated.
According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data Report, standard nuclear medicine imaging services ranked among the top 20 Part B service types for improper payments, with an overall rate of 14.3 percent.
Reason for Review
The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with PET myocardial perfusion imaging current procedural terminology (CPT) codes (78429, 78430,78431,78433,78434), SPECT myocardial perfusion imaging CPT codes (78451,78452), and Planar myocardial perfusion imaging CPT code (78454) billed with date of service January 1, 2024, through December 31, 2025.
The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.
Claim Sample Detail
| CPT | Description |
|---|---|
| 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 |
| 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 |
| 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 |
| 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 |
| 78434 | Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) |
| 78451 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection |
| 78454 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection |
Access related project details below.
Documentation Requirements
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- Please Note: The ordering or referring physician is responsible for forwarding appropriate clinical data to the receiving facility performing the cardiovascular nuclear test to identify the test and provide sufficient information supporting performance and interpretation
- Treating practitioner’s written order for the cardiovascular nuclear test
- Progress reports or office notes from the ordering or referring provider to the receiving facility to support the medical necessity of the cardiovascular nuclear test performance, including the medical indication and prognosis derived from the PET, SPECT, and/or Planar scan
- Relevant noninvasive cardiac tests within the last two years, if applicable
- Results and interpretation of the PET, SPECT, and/or Planar scan performed at the center for the date of service under review
- Previous results and reports for PET, SPECT, and/or Planar scan that support the date of service under review
- Preoperative and Perioperative evaluations including any and all anesthesia evaluations, if applicable
- Cardiac Perfusion Studies, if applicable
- Imaging studies including, but not limited to, CT or MRI that support the medical necessity of the PET, SPECT, and/or Planar scan ordered
- Documentation to support the code(s) and modifier(s) billed
- Electrocardiogram (EKG) and/or Echocardiogram report, including documented responses, when applicable
- Clinical indication(s) and management that necessitate the need for a PET, SPECT, and/or Planar study
- Any other supporting/pertinent documentation
- Medical record documentation to support national and local requirements
- Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record
- If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician.
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
- If medical record documentation is submitted via esMD, beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
References
Social Security Act (SSA), Title XVIII
- §1815(a) Payment to Providers of Services
- §1833(e) Payment of Benefits
- §1833(t) Hospital Outpatient Prospective Payment System (OPPS)
- §1834(e)(1)(B) Advanced Diagnostic Imaging Services Defined
- §1861(s) (2)(C) Medical and Other Health Services
- §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
- §1869(f)(1)(B) Determinations; Appeals
- §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
42 Code of Federal Regulations (CFR)
- §410.20 Physicians’ Services
- §410.32 Diagnostic X-ray Test, Diagnostic Laboratory Test, and Other Diagnostic Test: Conditions
- §410.33 Independent Diagnostic Testing Facility
- §411.15(k)(1) Particular services excluded from coverage
- §413.65 Requirements for a determination that a facility or an organization has a provider-based status
- §414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier
- §424.5 Basic Conditions
Internet-Only Manual (IOM), Publication (Pub.) 100-03, Medicare National Coverage Determination Manual (NCD)
- Chapter (Ch.) 1, Part 4 §220.6.1 PET for Perfusion of the Heart
- Ch. 1, Part 4 §220.6.8 FDG PET for Myocardial Viability
- Ch. 1, Part 4 §220.12 Single Photon Emission Computed Tomography (SPECT)
IOM, Pub. 100-02, Medicare Benefit Policy Manual (MBPM)
- Ch. 6, §20.4 Outpatient Diagnostic Services
- Ch. 6, §40 Other Covered Services and Items
- Ch.15, §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
- Ch. 16, General Exclusion from Coverage
IOM, Pub.100-04, Medicare Claims Processing Manual (MCPM)
- Ch. 1, General Billing Requirements
- Ch. 4, Part B Hospital (Including Inpatient Hospital Part B and OPPS)
- Ch. 13, §20 Payment Conditions for Radiology Services
- Ch. 13, §60 Positron Emission Tomography (PET) Scans – General Information
- Ch. 13, §50 Nuclear Medicine (CPT 78000-79999)
- Ch. 14, Ambulatory Surgical Centers
- Ch. 15, §260 Ambulatory Surgical Center Services
- Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
- Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)
- Ch. 35, Independent Diagnostic Testing Facility (IDTF)
IOM, Pub. 100-08, Medicare Program Integrity Manual (MPIM)
- Ch. 3, Verifying Potential Errors and Taking Corrective Actions
- Ch. 10, §10.2.2.4 Independent Diagnostic Testing Facility (IDTFs)
- Ch 13, §13.5.4 Reasonable and Necessary Provisions in LCDs
CMS Coding Policies
- National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Ch. 9 Radiology Services, § E. Nuclear Medicine. Effective January 1, 2023. Revision Date January 14, 2024
Local Coverage Determination (LCD)
- L33457 Cardiac Radionuclide Imaging
- L33560 Cardiovascular Nuclear Medicine
- L33910 Independent Diagnostic Testing Facility (IDTF)
- L33960 Cardiovascular Nuclear Medicine
- L35083 Cardiology Non-emergent Outpatient Stress Testing
- L35448 Independent Diagnostic Testing Facility (IDTF)
- L38396 Cardiology Non-emergent Outpatient Stress Testing
- L39521 Positron Emission Tomography (PET) Scan for Inflammation and Infection
Local Coverage Article (LCA)
- A53252 Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
- A56423 Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing
- A56476 Billing and Coding: Cardiac Radionuclide Imaging
- A56494 Billing and Coding: Cardiovascular Nuclear Medicine
- A56743 Billing and Coding: Cardiovascular Nuclear Medicine
- A56952 Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing
- A57807 Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
- A59318 Billing and Coding: Positron Emission Tomography (PET) Scan for Inflammation and Infection
Other
- American Medical Association CPT® Professional Edition (Christopher L. Jagmin & Barbara S. Levy, Eds.) (2023) (2024) (2025) American Medical Association
- American Society of Nuclear Cardiology About Nuclear Cardiology 2025 Retrieved from https://www.asnc.org/about-asnc/about-nuclear-cardiology/
- Comprehensive Error Rate Testing (CERT) 2024 Medicare Fee-for-Service Supplemental Improper Payment Data November 25, 2024 Retrieved from https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert/cert-reports/2024-medicare-fee-service-supplemental-improper-payment-data-1
- CMS Approved RAC Reviews 0010 – Cardiac Positron Emission Tomography Scans: Medical Necessity and Documentation Requirements 1/2/2024. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0010-cardiac-positron-emission-tomography-scans-medical-necessity-and-documentation-requirements
- Department of Justice (DOJ) Sixteen Cardiology Practices to Pay a Total of $17.7M to Resolve False Claims Act Allegations Concerning Inflated Medicare Reimbursements December 20, 2024. Retrieved from https://www.justice.gov/archives/opa/pr/sixteen-cardiology-practices-pay-total-177m-resolve-false-claims-act-allegations-concerning
- Medicare Learning Network (MLN) SE18002 Billing Requirements for OPPS Providers with Multiple Service Locations January 1, 2017. Retrieved from https://www.cms.gov/sites/default/files/2021-03/se18002.pdf
- National Library of Medicine Nuclear Cardiology for a Cardiothoracic Surgeon March 1, 2022. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9023643/
Last Updated May 12, 2026