CPT 78431Radiology

Myocrd img pet rst&strs ct

CPT code 78431 covers a specialized heart imaging test using PET (positron emission tomography) scanning combined with CT, performed during both rest and stress conditions to evaluate blood flow to the heart muscle.

Showing rates for

National Average

Base Medicare rate

$83.78

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

1.9

PE RVU (NF)

0.64

MP RVU

0.05

Total RVU

2.59

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

NCCI bundling edits

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Billing tips

Verify that both rest AND stress components are documented in the medical record before billing 78431. If only one component performed, use alternative codes (78459 for rest only).
Impact: Prevents denials and recoupment; billing 78431 without both components documented can result in 100% claim denial and potential fraud investigation
Document the specific radiopharmaceutical used (rubidium-82 chloride or nitrogen-13 ammonia) and dosage administered, as PET tracers have different acquisition protocols and costs.
Impact: Supports medical necessity and may affect facility cost reimbursement; rubidium-82 generators cost $30,000-50,000 monthly, impacting technical component justification
Ensure CT attenuation correction images are acquired and documented. CPT 78431 specifically includes CT; without CT documentation, you may need to bill a different code.
Impact: Code selection accuracy prevents downcoding to non-CT PET codes (if they existed in this family); maintains full $83.78 reimbursement versus potential denial
For Medicare patients, verify coverage under LCD (Local Coverage Determination) for cardiac PET, including approved indications and any prior authorization requirements specific to your MAC jurisdiction.
Impact: LCD non-compliance is the leading cause of denials for 78431; pre-verification prevents 100% payment denial and reduces appeal time by 30-60 days
When billing professional component (modifier 26), ensure interpretation report includes quantitative perfusion analysis, segmental scoring, and correlation with CT anatomy.
Impact: Comprehensive reporting supports the 1.9 work RVU and reduces audit risk; incomplete reports may trigger modifier 26 denials or downcoding

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Common denials

Medical necessity not established - payer requires prior SPECT imaging or specific clinical criteria before approving advanced PET imaging

How to appeal: Submit appeal with clinical notes documenting patient characteristics that make PET superior to SPECT (obesity with BMI >35, prior equivocal SPECT, breast attenuation, or small left ventricle). Include published guidelines from ASNC or ACC supporting PET as first-line imaging for specific patient populations. Reference LCD coverage criteria and demonstrate all requirements are met.

Incomplete documentation - stress component or rest component not clearly documented in medical record

How to appeal: Obtain addendum from interpreting physician clarifying both components were performed. Submit image timestamps showing separate rest and stress acquisitions. Provide radiopharmaceutical administration records showing two separate injections (one at rest, one at peak stress). Include stress protocol documentation (pharmacologic agent, dose, heart rate response).

Bundling denial - payer bundles 78431 with same-day cardiac CT or other cardiovascular imaging studies

How to appeal: Appeal with modifier 59 or XU (distinct procedural service) if not initially used. Provide documentation showing separate medical necessity for each study. Reference NCCI edits and demonstrate procedures are not components of each other. For cardiac CT performed same day, document different clinical questions answered by each modality (PET for perfusion/ischemia, CT for anatomic coronary assessment).

Facility versus professional component confusion - wrong modifier or no modifier used causing duplicate payment issues

How to appeal: Clarify billing arrangement with facility/physician. Submit corrected claim with appropriate modifier 26 (professional) or TC (technical). Provide service agreement or documentation showing split billing arrangement. If global service intended, appeal with documentation that single entity performed both components and owns/operates PET equipment.

Frequently asked questions

What is the Medicare reimbursement rate for CPT code 78431 in 2025?

The 2025 Medicare national average reimbursement rate for CPT code 78431 is $83.78 for both facility and non-facility settings. This rate is based on 2.59 total RVUs (1.9 work RVU + 0.64 PE RVU + 0.05 MP RVU) multiplied by the 2025 conversion factor of 32.3465. Actual reimbursement may vary by geographic locality based on GPCI adjustments.

Does CPT 78431 include both rest and stress imaging?

Yes, CPT code 78431 specifically requires both rest and stress myocardial PET imaging to be performed. The descriptor 'Myocrd img pet rst&strs ct' indicates both components must be documented. If only rest imaging is performed, a different code (such as 78459) should be used instead. Billing 78431 without both components constitutes incorrect coding and will result in claim denial.

What is the difference between CPT 78431 and 78432?

CPT 78431 includes CT imaging for attenuation correction and anatomic localization as part of the PET study, while 78432 describes myocardial PET imaging with rest and stress but without the CT component. The CT integration in 78431 improves diagnostic accuracy by correcting for photon attenuation artifacts. Most modern PET systems are PET/CT hybrids, making 78431 the more commonly billed code in current practice.

Can CPT 78431 be billed with modifier 26 for professional component only?

Yes, CPT 78431 can be billed with modifier 26 when only the professional component (physician interpretation and report) is provided, with the technical component billed separately by the facility. The work RVU of 1.9 represents the professional component value. Split billing is common when hospital-employed physicians interpret studies performed at hospital-based PET centers, or when independent physicians provide interpretations for imaging center studies.

What documentation is required to bill CPT 78431 for Medicare patients?

Medicare requires documentation of medical necessity (clinical indication), both rest and stress imaging acquisition with specific radiopharmaceutical details, stress protocol (pharmacologic agent or exercise details, hemodynamic response), CT attenuation correction confirmation, quantitative perfusion analysis with segmental scoring, left ventricular function assessment, and a comprehensive interpretation report correlating findings with clinical history. Local Coverage Determinations may specify additional requirements such as prior non-invasive testing or specific approved indications.

How many RVUs is CPT code 78431 worth in 2025?

CPT code 78431 has 2.59 total RVUs in 2025, consisting of 1.9 work RVUs, 0.64 practice expense RVUs (both facility and non-facility), and 0.05 malpractice RVUs. These values are from the CMS Medicare Physician Fee Schedule RVU25A released December 23, 2024. The work RVU of 1.9 reflects the physician time and intensity for interpreting complex cardiac PET/CT studies with both rest and stress components.

What are common denial reasons for CPT 78431 and how can they be prevented?

Common denials for CPT 78431 include lack of medical necessity (failure to meet LCD criteria), incomplete documentation of both rest and stress components, bundling with same-day cardiac imaging studies, and incorrect modifier use for component billing. Prevention strategies include verifying LCD compliance before ordering, ensuring comprehensive documentation of all procedural elements, using modifier 59 when billing with other cardiac studies (with strong medical necessity justification), and correctly applying modifier 26 or TC for split billing arrangements.