Documentation requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Medical records must substantiate the medical necessity of the services, including a clinical diagnosis and the specific reason for the study.
All segments of the service must have a formal interpretation and report.
The referral order must include the medical indication for the study, and be kept on file in the patient's medical record.
When a blood pool scan is performed to assess ejection fraction prior to implantation of defibrillator or biventricular pacemaker, the record must document the intended plan for insertion and the result of the test.
When billing for the purchase of radiopharmaceutical(s), a copy of the bill indicating the dosage administered, unit price per dose, name and total charge of the radiopharmaceutical must be on file in the patient's medical record and available on request.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 78451 | HCPCS | Covered |
| 78452 | HCPCS | Covered |
| 78453 | HCPCS | Covered |
| 78454 | HCPCS | Covered |
| 78466 | HCPCS | Covered |
| 78468 | HCPCS | Covered |
| 78469 | HCPCS | Covered |
| 78472 | HCPCS | Covered |
| 78473 | HCPCS | Covered |
| 78481 | HCPCS | Covered |
| 78483 | HCPCS | Covered |
| 78494 | HCPCS | Covered |
| 78496 |