Use This Guide to Tame PET Scan Coding Fears
Remember to note the drug supply type, as coding depends on it. There are high technical and professional reimbursement rates attached to positron emission tomography (PET) scans that your neurologist performs. Those high reimbursement rates come with increased payer scrutiny about the scans. To code them correctly, you’ll need to know, among other things, the exact type of PET scan your neurologist ordered, what drugs they administered, and whose equipment they used for the imaging. We got the answers you need from Angie Davis CPC, CDEO, during her HEALTHCON 2026 presentation “Mastering PET Scan Coding: Keys to Accuracy and Compliance.” Read on for more information about how to report PET scans properly. Understand PET Basics While this article focuses on PET scans of the brain, they can be performed on other parts of the body for a variety of reasons. In all instances, a PET scan is a functional imaging modality that measures metabolic and biochemical activity, according to Davis. The procedure uses a radiopharmaceutical tracer to detect cellular changes before structural changes. “PET imaging evaluates metabolic and physiologic activity within tissues,” said Davis. The scan can detect areas of: PET scans for neuro: Providers in neurology practices order PET scans for “evaluation of neurodegenerative disorders, seizure focus localization, potential brain tumor, and assessment of abnormal brain function when MRI/CT is inconclusive,” said Davis. Know PET Workflow When the neurologist orders a PET scan, the activities occur in this order: Know How Brain PET Works During a typical brain PET scan, fluorodeoxyglucose (FDG) is injected and enters brain cells to track glucose. “The brain uses glucose as its primary energy source, so areas of activity have a higher intake, and areas of dysfunction have a reduced uptake,” Davis explained. These areas indicate patterns of increased or decreased metabolism and regional brain activity differences. If the brain PET is for amyloid imaging, the mechanics of the scan change. “Now, amyloid imaging is different because those tracers bind to amyloid plaque in the brain. And in those studies, the tracer is retained where plaque is present,” she explained. Amyloid plaques are dense, insoluble clusters of misfolded proteins that accumulate between neurons in the brain, and they’re the hallmark of Alzheimer’s, said Davis. During an amyloid PET, the neurotracer binds “to amyloid plaque in the brain, allowing the study to show whether plaque deposition is present or absent,” she said. For PET imaging to be considered medically necessary, the study should: Get to Know PET Scan Service Codes A large swath of your PET scan encounters will involve one of the following two codes: Although not used as often as 78608 and 78609, these codes could come into play when neurologic indications involve tumors or amyloid imaging: 78811 (Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)) through 78816 (Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body) You should also code separately for the tracer your neurologist uses during the PET scan. These are the most common tracer codes, according to Davis: When coding for the tracer, you should include the following information: Important: The majority of brain PET scans will use A9552 as a tracer because they are tracking glucose. Codes A9586, Q9982, and Q9983 are used during amyloid PET scans. Dig Detail From Payer Contracts for Amyloid Coverage Info Coverage policies for amyloid PET scans are evolving. This means that the service is “often noncovered or highly restricted. [It also] may require research protocol or registry participation,” said Davis. “Amyloid PET is a good example of where clinical value and coverage don’t always align. The documentation needs to clearly show why advanced imaging is ordered now, what uncertainty exists, and how the results are expected to influence a patient’s management,” said Davis. Your claims are more likely to face scrutiny without including all of the details outlined above. Remember Modifiers for Drug Waste, Professional Component When reporting the tracer, you need to append modifier JW (Drug amount discarded/not administered to any patient) or JZ (Zero drug amount discarded/not administered to any patient), as appropriate. This applies only to single-dose containers and vials or single-dose packages; don’t use the modifiers on multidose vials, said Davis. When using modifier JW, record the discarded drug amount on a separate claim line from the administered dose. If the neurologist performs PET scans using the practice’s equipment, then you can report your PET scans without any further modifications. When the PET scan occurs with another facility’s equipment, coding changes slightly. Do this: Append modifier 26 (Professional component) to the PET scan CPT® code that you choose. So if the neurologist performs a perfusion brain PET using a local hospital’s equipment, you would report 78609-26. Also, only the provider that incurred the costs of the radiopharmaceuticals can code for them. So if the hospital provides the FDG for your neurologist’s PET scan, don’t code for it. Know These PET Pitfalls When a PET scan claim fails, it is often due to one of these reasons, Davis said: Chris Boucher, MS, CPC, Senior Development Editor, AAPC
