Neurology & Pain Management Coding Alert

Sometimes, the physician will order both tests at the same time.

Positron emission tomography (PET) scans are nuclear medicine imaging studies used to detect normal and abnormal tissues. These scans are often used to map brain functioning, along with providing cancer diagnoses and treatment options. These scans can be helpful when trying to identify bodily changes, metabolic variations, blood flow, and oxygen usage.

Providers frequently use PET and computed tomography (CT) scans to detect and locate cancer, cardiovascular and brain disorders, as well as a variety of other health problems.

Take a look at the basics of PET scans, and how CT scans can help fit the bill in certain situations.

Know These PET Scan Basics

A PET scan consists of three major elements:

• Radiotracer injection: The provider injects a small amount of a radioactive substance (radiotracer) into the patient’s bloodstream. This substance is usually a form of glucose because cancer cells and other active tissues often consume glucose at higher rates than normal tissues.
• Scanner: The PET scanner detects the radiation emitted by the tracer. The scanner creates detailed images showing where the tracer accumulates in the body.
• Images: These images help doctors assess tissue function and identify abnormalities such as tumors, inflammation, or infections.

Know These CT Scan Basics

CT scans are often performed concurrently with PET scans to retrieve the full picture of the human body as it functions. A CT scan is a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body. The benefit of both these procedures is that they typically are noninvasive in nature — meaning they do not require surgery for diagnostic purposes. Using the PET and CT machines together can offer the most accurate cancer diagnosis based on staging and malignancy detection.

These two services are often billed together as concurrent scans, but coders need to look at what the Centers for Medicare & Medicaid Services (CMS) has to say about the performance of same-day CT and PET scans.

Check Out This PET Scan Coding Guidance

Let’s cover the ins and outs of PET scan coding and billing guidelines. A solid understanding of these tests will be integral to any coder’s repertoire, so we will be discussing the CPT^® codes, modifiers, and the radiopharmaceutical tracer codes that should all be reported together.

Below are the CPT^® codes for singular PET scans, or those without a concurrent CT scan:

• 78811 (Positron emission tomography (PET) imaging; limited area (e.g. chest, head/neck))
• 78812 (… skull base to mid-thigh)
• 78813 (… whole body).

Below are the CPT^® codes for PET scans with a concurrent CT scan:

• 78814 (Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (e.g., chest, head/neck))
• 78815 (… skull base to mid-thigh)
• 78816 (… whole body).

Per the CPT^® parentheticals, these codes should only be billed once per imaging session.

Remember to Include Tracer Coding

All PET scan services require a radiopharmaceutical code, also known as a tracer code, to be billed. The tracer code must be billed on the same date of service as the PET scan CPT^® code.

The tracer codes are:

• A9597 (Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified)
• A9598 (Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified).

Follow CMS Modifier Guidelines

Below are helpful guidelines from CMS in the national coverage determination (NCD) article 53134. (Please note to refer to your Medicare Administrative Contractor’s [MAC’s] applicable article for guidance in your region.):

According to CMS, the procedure codes listed for PET scans represent the global service. Therefore, providers performing only the technical or professional component of the test should use modifier TC (Technical component) or 26 (Professional component), respectively.

There are also modifiers specific to PET scans to indicate the stage in which the diagnostic study is performed in relation to the patient’s treatment plan.

For initial treatment strategies, you should use modifier PI (Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing).

You will then apply modifier PS (Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy) to all subsequent studies.

Follow This Advice on Same-day PET and CT Scans

Per CMS, “If a PET scan is obtained and, on the same date of service, diagnostic CT scan(s) are obtained at a separate session, then both the PET scan and the CT scan(s) may be coded individually. If a PET/CT study is performed concurrently on a hybrid PET/CT scanner and an additional diagnostic CT scan is also obtained non-concurrently, it is appropriate to code the PET/CT scan and the diagnostic CT scan(s) separately (whether the diagnostic CT scans are performed on a hybrid PET/CT scanner or on a dedicated CT scanner). To further clarify, the CT component of a PET/CT scan is for concurrently obtained CT scans for attenuation correction and localization and does not include any additional diagnostic CT studies that may be requested.”

PET and CT scans are powerful diagnostic tools used by physicians, and coders need to be fully versed in their various billing constraints. By following these guidelines, you can ensure that PET scan procedures are coded accurately and in accordance with payer requirements.

Jessica Sullivan, CPC, COBGC, COSC, Consultant,
Pinnacle Enterprise Consulting Services (PERCS)