Myocardial perfusion imaging, tomographic (SPECT), single study at rest or stress (exercise or pharmacologic); with or without wall motion, qualitative or quantitative wall motion, ejection fraction and/or first pass
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Nuclear stress test medical necessity not established - stress echo or ECG adequate
Very Common78451 (myocardial perfusion imaging, nuclear stress) most expensive stress test option. Denied when less expensive alternatives appropriate (stress ECG, stress echo), when ordered for low-risk screening, or when patient cannot achieve adequate stress (pharmacologic not justified). Indicated when: unable to exercise (need pharmacologic), prior stress echo non-diagnostic, evaluating known CAD extent.
Common Causes
- • Nuclear stress as first-line test - should try stress ECG or echo first unless contraindicated
- • Patient able to exercise but ordered pharmacologic stress - exercise preferred when possible
- • No cardiac symptoms, ordered for screening - not covered
Resolution Strategy
Document specific indication for nuclear over alternatives: 'Patient with exertional chest pressure, high pretest probability CAD. Unable to perform exercise stress test due to severe osteoarthritis and bilateral knee replacements. Pharmacologic nuclear stress (regadenoson protocol) necessary to assess for myocardial ischemia. Resting images show normal LV size and function. Stress images demonstrate reversible perfusion defect in LAD territory, moderate intensity, concerning for significant stenosis. Referred for cardiac catheterization.' Alternative: 'Prior stress echo technically inadequate due to poor echo windows (obesity, COPD). Nuclear perfusion imaging necessary to evaluate chest pain. Exercise protocol achieved target heart rate.' Must specify: why nuclear needed over ECG/echo, why pharmacologic if not exercise, cardiac symptoms, how results change management. Pre-op clearance alone insufficient. Cannot appeal screening or patient preference.
Relative Value Units (RVUs)
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Clinical Information
When to Use
For myocardial perfusion SPECT imaging, single study at rest or stress
Common Scenarios
Documentation Requirements
- Indication for myocardial perfusion imaging
- Type of stress used (exercise vs pharmacologic)
- Myocardial perfusion findings
- Wall motion assessment
- Ejection fraction if performed
Coding Guidelines
Common Modifiers
Bundling Rules
- Includes single study at rest or stress
- Includes SPECT imaging
- Wall motion assessment bundled
- Ejection fraction bundled
- Multiple studies coded separately
Exclusions
- 78452 (myocardial perfusion imaging, SPECT, multiple studies)
- 78453 (myocardial perfusion imaging, planar, single study)
- 78454 (myocardial perfusion imaging, planar, multiple studies)
- 93015 (cardiovascular stress test)
Coding Notes
Clinical scenarios
- Indication for myocardial perfusion imaging
- Type of stress used (exercise vs pharmacologic)
- Myocardial perfusion findings
- Indication for myocardial perfusion imaging
- Type of stress used (exercise vs pharmacologic)
- Myocardial perfusion findings
- Indication for myocardial perfusion imaging
- Type of stress used (exercise vs pharmacologic)
- Myocardial perfusion findings
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Ask a QuestionFrequently Asked Questions
CPT 78451 is the billing code for "Myocardial perfusion imaging, tomographic (SPECT), single study at rest or stress (exercise or pharmacologic); with or without wall motion, qualitative or quantitative wall motion, ejection fraction and/or first pass". For myocardial perfusion SPECT imaging, single study at rest or stress
Medicare pays approximately $296.94 for CPT 78451 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 78451 has a total RVU of 11.25, broken down as: Work RVU 2.50, Practice Expense RVU 8.50, and Malpractice RVU 0.25. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 78451 is "Nuclear stress test medical necessity not established - stress echo or ECG adequate". 78451 (myocardial perfusion imaging, nuclear stress) most expensive stress test option. Denied when less expensive alternatives appropriate (stress ECG, stress echo), when ordered for low-risk screening, or when patient cannot achieve adequate stress (pharmacologic not justified). Indicated when: unable to exercise (need pharmacologic), prior stress echo non-diagnostic, evaluating known CAD extent. Common causes include: Nuclear stress as first-line test - should try stress ECG or echo first unless contraindicated; Patient able to exercise but ordered pharmacologic stress - exercise preferred when possible. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 78451 include: Indication for myocardial perfusion imaging; Type of stress used (exercise vs pharmacologic); Myocardial perfusion findings; Wall motion assessment. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 78451: Includes single study at rest or stress. Includes SPECT imaging Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 78451 include: 26 (Professional component only (interpretation)), TC (Technical component only (equipment/staff)), 59 (Distinct procedural service if performed separately). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 78451 is 30-60 minutes typical procedure time. Time-based codes require documentation of the actual time spent providing the service.