CPT 78428Radiology

Cardiac shunt imaging

CPT code 78428 covers cardiac shunt imaging, a nuclear medicine test that uses radioactive tracers to detect abnormal blood flow patterns between heart chambers or major blood vessels. This procedure helps identify congenital heart defects and circulatory abnormalities.

Showing rates for

National Average

Base Medicare rate

$165.61

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.78

PE RVU (NF)

4.27

MP RVU

0.07

Total RVU

5.12

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Separately document radiopharmaceutical administration and specify the agent used (Tc-99m MAA, Tc-99m DTPA, or Tc-99m albumin) as radiopharmaceutical codes may be separately billable
Impact: Additional $50-150 in radiopharmaceutical reimbursement depending on agent and dose
Verify split/shared visit documentation when procedure spans hospital and professional billing - ensure time-based elements and technical supervision are clearly documented
Impact: Prevents duplicate billing denials and ensures proper component reimbursement totaling $165.61
Document shunt quantification calculations (Qp/Qs ratios) in the interpretation report as payers may deny if only qualitative assessment is provided
Impact: Reduces denial rate by approximately 15-20% based on incomplete documentation
Bill on same claim date as injection procedure; ensure injection timing and imaging protocol are documented within the same encounter
Impact: Prevents unbundling denials and timing-related payment delays
For pediatric patients, document weight-based dosing calculations and reduced acquisition times to support medical necessity and radiation safety compliance
Impact: Strengthens medical necessity documentation and reduces audit risk by 30%
When billing with echocardiography on same date, append modifier 59 only if separate clinical indication exists and document distinct diagnostic purpose
Impact: Preserves $165.61 payment that would otherwise be bundled or denied

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Frequently asked questions

What is the 2025 Medicare reimbursement rate for CPT code 78428?

The 2025 Medicare national average reimbursement rate for CPT 78428 is $165.61 for both facility and non-facility settings. The code has a total RVU value of 5.12, comprising 0.78 work RVU, 4.27 practice expense RVU, and 0.07 malpractice RVU.

Can CPT 78428 be billed with an echocardiogram on the same day?

Yes, but it requires careful documentation of separate medical necessity. Append modifier 59 to 78428 and document distinct clinical indications for each study. The nuclear shunt study must provide information not obtainable from echocardiography, such as precise quantification of shunt ratio or evaluation when echo windows are inadequate.

What radiopharmaceuticals are used for cardiac shunt imaging under code 78428?

Common radiopharmaceuticals include Tc-99m labeled macroaggregated albumin (MAA), Tc-99m DTPA, or Tc-99m pertechnetate. The specific agent should be documented in the procedure report, and radiopharmaceutical supply may be separately billable depending on payer policies and practice setting.

Is prior authorization typically required for CPT 78428?

Most Medicare Advantage plans and commercial payers require prior authorization for cardiac nuclear imaging including 78428. Authorization requirements vary by payer and typically require documentation of clinical indication, prior non-invasive testing results, and explanation of why this specific imaging modality is necessary.

How do you calculate the shunt ratio for CPT 78428 documentation?

The shunt ratio (Qp/Qs) is calculated by comparing pulmonary blood flow (Qp) to systemic blood flow (Qs) using time-activity curves from regions of interest over the lungs and systemic circulation. A ratio greater than 1.5:1 typically indicates a significant left-to-right shunt. Document the methodology, ROI placement, and numerical ratio in the interpretation report.

What modifier should be used when only interpreting a cardiac shunt study performed at another facility?

Use modifier 26 (professional component) when providing only the interpretation of images acquired at another facility. This modifier indicates you are billing only for the physician work of reading and reporting the study, not the technical equipment and staff costs. The 26 modifier reimbursement is a subset of the total $165.61 rate.

What is the difference between CPT 78428 and other cardiac nuclear medicine codes?

CPT 78428 specifically covers shunt detection and quantification imaging, while codes like 78451-78454 cover myocardial perfusion imaging, 78472 covers gated blood pool studies, and 78481-78483 cover cardiac blood pool imaging. Each code represents distinct protocols and clinical indications, and they should not be confused or substituted for one another.