CPT 78459Radiology

Myocrd img pet single study

CPT code 78459 covers a single PET scan of the heart muscle to evaluate blood flow and detect areas of damage or reduced oxygen supply. This nuclear medicine test helps diagnose coronary artery disease and assess heart muscle viability.

Showing rates for

National Average

Base Medicare rate

$70.19

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

1.61

PE RVU (NF)

0.51

MP RVU

0.05

Total RVU

2.17

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

NCCI bundling edits

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Billing tips

Verify coverage determination through National Coverage Determination (NCD) 220.6 for PET cardiac imaging before scheduling, as Medicare requires specific clinical indications including assessment of myocardial viability prior to revascularization
Impact: Prevents denials averaging $200-400 per study; prior authorization compliance can reduce denial rate by 80%
Document the specific radiopharmaceutical used (rubidium-82, nitrogen-13 ammonia, or fluorine-18 FDG) as different tracers may have different coverage policies and some payers require specific agents
Impact: Ensures proper reimbursement and prevents downcoding; radiopharmaceutical choice can affect total reimbursement by $300-600
Do not bill 78459 with stress codes (93015-93018) or pharmacologic stress agents on the same date as this is a single rest study; use 78491-78492 for stress/rest protocols instead
Impact: Prevents unbundling denials and potential recoupment; incorrect bundling can result in 100% denial of one service ($70.19 loss minimum)
Submit the physician interpretation report within 24-48 hours of image acquisition and ensure it includes all required elements per ACR standards including technical quality assessment, perfusion patterns, and clinical correlation
Impact: Reduces medical review requests by 60% and strengthens appeal success rate to over 85% when documentation is complete
Bill facility and professional components separately when appropriate using modifiers 26 and TC; verify your practice's ownership/lease status of PET equipment to determine correct billing approach
Impact: Ensures maximum appropriate reimbursement; incorrect component billing can result in 40-60% payment reduction

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 78459 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 78459 is $70.19 for both facility and non-facility settings. This is based on a total RVU of 2.17 multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic location due to locality adjustments.

Does CPT 78459 include both rest and stress imaging?

No, CPT 78459 represents a single myocardial PET study only, typically performed at rest. For complete stress and rest protocols, you should use CPT 78491 (single study with stress) or 78492 (multiple studies). Billing 78459 with separate stress testing codes on the same date will typically result in denials.

What diagnosis codes support medical necessity for CPT 78459?

Commonly accepted diagnosis codes include I25.10-I25.9 (chronic ischemic heart disease), I25.5 (ischemic cardiomyopathy), I20.0-I20.9 (angina pectoris), and I24.x (other acute ischemic heart disease). Per NCD 220.6, the most defensible indication is assessment of myocardial viability prior to revascularization in patients with known coronary disease and left ventricular dysfunction.

Can CPT 78459 be billed with modifier 26 for professional component only?

Yes, modifier 26 should be appended when billing only the physician interpretation component, typically when a radiologist or cardiologist reads images acquired at a separate facility. The technical component (equipment, radiopharmaceutical, staff) would be billed separately by the facility using modifier TC. Verify the split matches your actual service arrangement.

What is the difference between CPT 78459 and 78491?

CPT 78459 is a single myocardial PET study (usually at rest), while CPT 78491 includes pharmacologic or exercise stress with a single study. If you perform both rest and stress imaging, use 78492 instead. Using the wrong code can result in significant undercoding (if you bill 78459 for stress protocol) or denial for unbundling (if you bill 78459 plus separate stress codes).

How often can CPT 78459 be billed for the same patient?

Medicare and most payers don't specify a hard frequency limit in national policy, but cardiac PET imaging is generally considered reasonable 1-2 times per year unless there's documented change in clinical status, new symptoms, or interval cardiac events. Some Medicare Advantage plans and commercial payers limit to one study per 12 months. Always check your local MAC LCD and individual payer policies.

What are the work RVUs for CPT code 78459?

CPT 78459 has a work RVU of 1.61, practice expense RVU of 0.51 (both facility and non-facility), and malpractice RVU of 0.05, for a total of 2.17 RVUs. These values are from the CMS 2025 Medicare Physician Fee Schedule released December 23, 2024. The work RVU reflects physician time and intensity for image interpretation and reporting.