Wiki 78815 pet scan denials

[kathleeng]

I recently started working for an oncology/hematology practice. Our radiation department bills out pet/ct scans very often 78811-78816 with varying diagnosis' ranging from primary cancer, secondary cancer, history of cancer, and others with suspected cancers. We have a history of receiving quite a lot denials on these. We do use the P1, PS, and have tried TC. We have also billed without these and they are still always denied. Is there a trick to billing these correctly, besides the norm? I know Medicare deems these experimental but how else are we to get paid for these scans if we have already taken all other measures prior to billing the pet scan? Anyone have any information on this? Since I'm new to this group, I'm am just trying to dive in to tackle this issue. Any help would be greatly appreciated!

 

[trarut]

I used to work for a practice with it's own Radiology department and we did a lot of PET scans). My thoughts, in no particular order :

• 78816 (whole body) is generally ordered only for melanoma patients and it's very difficult to get it covered for any other indication.
• Most were FDG PETs (78815 skull to mid-thigh for staging or re-staging)
• There aren't many indications for PET that Medicare deems experimental these days but there are a few - the NaF bone PET comes to mind first and foremost. Your patients must be enrolled in the NaF PET registry then, if they're approved, the PET code should be billed with a Q0 modifier. I posted a link to the CMS PET NCD on your other post before I saw this one.
• None of the plans like to pay for PET scans for "suspected" cancers. They want a known malignancy identified on CT scan (or other imaging) with the PET used to determine extent of disease.
• Make sure you're using the TC modifier appropriately. Where I worked, we owned the equipment and did the scans but did not do the interps so we billed technical (TC) only. Prior to that we billed globally because we did the scans and interps so no modifiers needed.
• Spend a little time digging into the coding and reimbursement policies of your biggest payers or the ones you're consistently having modifier denials with to see if they even recognize PI and PS. Just because coding rules and CMS say to use them doesn't mean every payer is accepting them.

Happy to help with any other questions if I can. Good luck!

 

[Sullivdr]

220.6.17 CMS gives a full list of payable dx codes