RaeToll
Networker
I received a Medicare claim rejection for CPT code 78816-PIPO (PET/CT whole body) citing inconsistent modifier or required modifier is missing. The primary diagnosis listed on the claim is C61 (malignant neoplasm of prostate). I reviewed the CMS Billing and Coding policy which states, Claims for FDG PET or imaging for oncologic indications for initial treatment strategy must include the “PI” modifier. Claims for FDG PET imaging for oncologic indications for subsequent strategy must include the “PS” modifier.
The physician order reads, 72 years -old Male with high risk prostate cancer, Gleason 9, needing imaging to assess for metastases. The purpose of this scan is for initial anti tumor treatment strategy, initial staging. The imaging findings read, "Ga68 gozetotide PET/CT demonstrates intense abnormal increased PSMA radiotracer uptake in the prostate, consistent with newly diagnosed prostate cancer."
When I run the codes in encoder as billed (78816-PIPO with diagnosis C61) I receive, "Per LCD or NCD guidelines, procedure code 78816 has not met the associated Modifier Code relationship criteria for CMS ID(s) 220.6.17."
When I change the modifier to -PS the claim comes up clean.
Am I not supposed to bill modifier -PI with a cancer diagnosis? I can't find CMS documentation that says either way and I feel the documentation supports the use of modifier PI.
I appreciate anyone that can shed some light on this issue.
The physician order reads, 72 years -old Male with high risk prostate cancer, Gleason 9, needing imaging to assess for metastases. The purpose of this scan is for initial anti tumor treatment strategy, initial staging. The imaging findings read, "Ga68 gozetotide PET/CT demonstrates intense abnormal increased PSMA radiotracer uptake in the prostate, consistent with newly diagnosed prostate cancer."
When I run the codes in encoder as billed (78816-PIPO with diagnosis C61) I receive, "Per LCD or NCD guidelines, procedure code 78816 has not met the associated Modifier Code relationship criteria for CMS ID(s) 220.6.17."
When I change the modifier to -PS the claim comes up clean.
Am I not supposed to bill modifier -PI with a cancer diagnosis? I can't find CMS documentation that says either way and I feel the documentation supports the use of modifier PI.
I appreciate anyone that can shed some light on this issue.