Coronary artery calcium (CAC) scoring has become one of the most widely used preventive cardiology imaging tools for stratifying a patient’s risk of coronary artery disease. Although clinically valuable, CT calcium scoring (CPT 75571) is one of the most strictly regulated imaging services in terms of billing and payer coverage.
This guide provides a complete, realistic breakdown of what 75571 covers, Medicare rules, commercial payer rules, medical necessity challenges, documentation requirements, bundling issues, common denials, and proper coding practices.
The purpose is to equip cardiology groups, radiology departments, and billing teams with the information necessary to handle 75571 correctly and compliantly.
Understanding CPT 75571
CPT 75571 — Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.
The service includes:
- Non-contrast CT imaging of the heart
- Quantitative scoring of coronary artery calcium (typically Agatston scoring, volume scoring, or mass scoring)
- Physician interpretation and report
- Use of ECG gating (prospective or retrospective)
It does not include CTA, contrast, perfusion imaging, or anatomic lumen visualization.
Key Point:
CPT 75571 is a preventive test and is often considered “screening”—therefore, most payers DO NOT COVER IT.
This is the single biggest billing pitfall.
When Calcium Score CT Is Appropriate
From a clinical perspective, CAC scoring is commonly used for:
- Intermediate-risk adults (10-year ASCVD risk 5%–20%)
- Risk reclassification
- Considering statin therapy initiation
- Assessing silent coronary atherosclerosis
- Strong family history of premature CAD
- Earlier detection of coronary calcification in high-risk populations
From a billing perspective, these are often not covered indications, even if clinically appropriate.
Medicare and most commercial payers categorize CAC scoring as:
- Screening
- Preventive
- Non-covered unless specifically included in policy
For this reason:
75571 is often billed as patient self-pay, using ABNs or financial waivers.
Coverage Rules by Payer Category
Medicare
Medicare does not cover coronary calcium scoring.
It classifies 75571 as a screening exam, and screening CT heart scans are statutorily excluded.
Billing options:
- Issue an ABN (Advance Beneficiary Notice of Noncoverage)
- Bill the patient directly
- Do NOT submit 75571 to Medicare unless ABN is signed (if you choose to submit)
- Use the GA modifier if submitting with ABN
- Use the GZ modifier if NO ABN was signed (automatic denial)
Medicare will not pay for 75571 under any circumstances.
Commercial Payers
Commercial insurers vary widely:
- Some cover CAC for defined criteria (rare)
- Some cover only with severe risk factors
- Most still classify CAC as preventive and non-covered
- Nearly all allow self-pay programs
Common policy language:
- “Experimental and investigational.”
- “Screening only”
- “Not medically necessary for asymptomatic patients.”
- “Considered preventive; not a covered benefit.”
Billing teams should:
- Verify plan coverage
- Maintain a standard CAC price
- Collect payment upfront
- Document patient financial liability acknowledgment
Medicaid
Most Medicaid programs do not cover 75571.
Many state policies explicitly exclude preventive cardiac CT imaging.
Technical & Professional Components of CPT 75571
Calcium scoring can be billed as:
- 75571 (global)
- 75571-26 (professional only)
- 75571-TC (technical only)
Billing varies by:
- Hospital outpatient
- Freestanding imaging center
- Provider-based clinic
- Office with CT equipment
Medicare’s OPPS system assigns 75571 to APC 5571 (Level 1 Imaging without contrast).
Reimbursement varies by locality.
Documentation Requirements for 75571
Even if the patient is self-pay, complete medical documentation is essential for compliance.
A compliant requisition and report must include:
- Clinical indication (e.g., coronary risk assessment)
- Technique (non-contrast, ECG gating, slice thickness)
- Quantitative calcium score
- Agatston
- Volume
- Mass
- Specific coronary arteries assessed
- LM
- LAD
- LCx
- RCA
- Interpretation describing score meaning in context:
- 0 = no detectable CAC
- 1–99 = mild
- 100–399 = moderate
- 400+ = extensive
- Risk stratification language
- Comparison with reference data (e.g., percentile ranking)
- Management considerations (statin, lifestyle counseling, risk discussion)
Important:
The report must clearly state that the scan was non-contrast.
Coding and Billing Considerations That Affect Payment or Denials
1. Medical Necessity Is Rarely Accepted
Most denials cite:
- “Service considered screening”
- “Not medically necessary.”
- “Not a covered benefit”
2. CAC Cannot Be Used to Justify CTA Billing
You cannot “upgrade” to CTA if the payer denies CAC.
3. CAC Is Not a Replacement for a Stress Test or an Echo
Some billing errors occur when CAC results are used to justify same-day stress testing.
4. CAC Cannot Be Billed With CTA Codes (75572–75574)
Calcium score is included in CTA coding only when a contrast study is performed for another reason.
However, CTA codes already include a limited CAC component when obtained concurrently.
5. Do Not Bill Calcium Score with Chest CT
Chest CT with incidental CAC does not allow billing 75571 as a separate study.
6. Avoid Using Unrelated Diagnosis Codes to Force Coverage
Payers audit for diagnosis manipulation.
7. If Self-Pay, Do Not Submit Claims Automatically
You may risk:
- Confusion
- Medicare audit flags
- Returned or denied claims
Keep self-pay documentation internal unless otherwise requested.
Appropriate & Inappropriate Diagnosis Codes
Whether or not payers cover 75571, documentation still requires ICD-10 codes.
Common Appropriate diagnostic descriptors (clinical, not coverage guarantees):
- Family history of premature coronary disease (Z82.49)
- Hyperlipidemia (E78.5)
- Pre-hypertension (R03.0)
- Cardiovascular screening (Z13.6)
- Risk assessment (Z91.89)
- Abnormal EKG (R94.31)
- Long-term statin therapy assessment (Z79.899)
Diagnoses that may trigger denials:
- Screening codes (Z13.6) — ironically, the most accurate
- Encounter codes without associated risk
- Missing risk factors
However:
Accuracy > Coverage
Coders should not code diagnoses solely to improve payment probability.
Compliance Requirements
Informed Financial Consent
For self-pay CAC programs, obtain:
- Written acknowledgment of noncoverage
- Agreed pricing
- Method of payment
- Separate signature from consent for medical procedure
ABN for Medicare
Must:
- Be issued before service
- Explain financial responsibility
- Specify CPT 75571
- Include the patient’s signature
Failure to document ABN → patient not responsible → provider must write off the amount.
NCCI / Bundling Compliance
- Calcium scoring cannot be billed with CTA unless distinct sessions or indications exist
- ECG gating is included
- Post-processing reconstructions are included
- No separate 3D processing codes allowed
Common Denials & How to Prevent Them
1. “Service Not Covered” (Most Common)
Prevent by:
- Verifying payer rules
- Using upfront self-pay models
- Not submitting claims unless required
2. “Experimental/Investigational.”
Avoid unnecessary appeals — this is a policy issue, not a documentation issue.
3. “Screening Service Not a Plan Benefit.”
Use self-pay or waiver documentation.
4. “Mismatch Between Report and CPT Code.”
Occurs if:
- Contrast used
- The report implies CTA
- Calcium scoring is described during full CTA but billed separately
5. Missing Professional Interpretation Documentation
Ensure the radiologist/cardiologist includes:
- Score
- Interpretation
- Risk category
- Clinical meaning
Pricing Strategies (Compliance-Focused, Not Sales-Oriented)
Many cardiology groups adopt fixed CAC pricing, such as:
- $75
- $99
- $125
- $150
Compliance notes:
- Prices must be published clearly
- Same price for insured and uninsured patients
- Avoid “insurance price vs cash price” differentials
- Keep consistent across all patient types to avoid compliance scrutiny
Operational Best Practices
Standardized Protocols
Every imaging center should have:
- Uniform acquisition technique
- Clear documentation template
- Required data elements (Agatston + percentile)
- Clear storage of raw DICOM data
Billing Team Workflow
- Verify payer coverages
- Mark Medicare patients for ABN
- Apply TC/26 correctly
- Confirm physician documentation before claim creation
- Use proper POS codes
- Log self-pay consents
Clinical Workflow
- Providers discuss risk scoring implications
- Use results for shared decision-making
- Avoid same-day “screening cascades” that may trigger audits
Conclusion
Calcium scoring CT (75571) is a clinically powerful but billing-complex study due to its classification as preventive/screening by Medicare and most commercial insurers. Understanding coverage exclusions, proper self-pay workflows, documentation requirements, appropriate coding, and bundling restrictions is essential to avoid denials and compliance risk.
Cardiology and radiology practices often develop standardized CAC workflows or consult external RCM experts such as Global Tech Billing LLC to support accurate, compliant imaging billing.
FAQs
1. What does CPT 75571 include?
A non-contrast, ECG-gated CT heart scan with quantitative coronary calcium scoring and physician interpretation.
2. Does Medicare cover calcium scoring CT?
No. Medicare classifies 75571 as a screening service and does not cover it.
3. Do commercial insurers cover 75571?
Most do not; some may cover selectively based on risk factors.
4. Can calcium scoring be billed with CTA codes?
No. Calcium scoring is bundled into CTA and cannot be billed separately with 75572–75574.
5. Is an ABN required for Medicare patients?
Yes, if billing or collecting payment. Without an ABN, the provider must write off the charge.
6. What documentation is required?
Clinical indication, technique, calcium scores per artery, total score, percentile, and interpretation.
7. Can CAC be billed if performed during a chest CT?
No. Incidental calcium findings on chest CT do not justify using 75571.
8. What makes CAC a common denial?
It is considered a preventive screening test and usually not a covered benefit.
