Pet imaging (78815) w/ c79.51

Rdrcoder

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I am wondering if anyone else has run into an issue with Medicare when billing CPT 78815 with Diagnosis code C79.51. We bill for the radiologist reading (technical component) and they are saying when we bill with the C79.51 we need to use modifier Q0. Modifier Q0 is used for services defined as an investigational clinical service provided in clinical research study that is in an approved clinical research study. Our patients are not part of a research study. I have reached out to the hospital that the patients go to, to have the CT done and we have billed everything the same except for the fact that we have the 26 modifier on ours.

I am just wondering if anyone else is experiencing this or have any suggestions as to what we should do at this point?
 
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DX Coding

Are you using one of the modifiers, PI or PS with the CPT code? PI is for the initial treatment strategy and PS is for subsequent treatment strategy. One of these modifiers needs to be used when billing for the pet scan.
 

Rdrcoder

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Are you using one of the modifiers, PI or PS with the CPT code? PI is for the initial treatment strategy and PS is for subsequent treatment strategy. One of these modifiers needs to be used when billing for the pet scan.

I have the correct PI and PS modifiers on the charges. So I am not understanding what else it could be.
 

skpartiss

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78815

From what I have read 78815 is non-covered for bone metastases. NCD 220.6.17 says Medicare determined not to cover for this dx.
 

mitchellde

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Look at the reason for the PET scan.. Usually these are performed to see if the cancer has metastasized to other areas so you should use the Neoplasm dx first listed and any active metastatic sites secondary. Just a thought without seeing the actual order I can only guess.
 
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PET scans

Unfortunately, I am running into the same problems with PET scans. Denials for several neoplasms C61 being one of them on the 78815 scan. I can't make heads or tales out of the explanation CMS is giving.
 

Sullivdr

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I only am coding the primary cancer dx (not the secondary). There is a good website NCCN image criteria that lists payable codes for PETs. I interpret it to say that we know the pt has the primary dx, coding the secondary (to me) is like coding to "rule out"
 

kathleeng

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Our facility is having the same issue. None of our pet scans are being paid. With and without the P1, PS, TC modifiers. No matter the dx whether is primary, secondary, suspected or hx of cancer. Unsure where to go from here. Any answers yet?
 

trarut

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Was an NaF or FDG PET ordered? NaF PET scans (or bone PETs) are considered investigational by CMS. There is a registry/clinical trial for patients getting these scans but they must be enrolled prior to having the scan. If the enrollment is completed, the Q0 modifier can be submitted to Medicare with the CPT code for the scan.

If you Google "NaF PET Registry", you'll get several helpful links.

Also, I'm assuming the patient has known bone mets and this wasn't a "rule out bone mets" situation. If your patient has bone mets with an unknown primary and the PET is ordered to identify the primary site of disease, I would use the unknown primary ICD-10 code as the primary diagnosis for the scan and isotope.
 

csperoni

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I do not see a Medicare LCD for Texas for 78815 or 78816 (per SuperCoder). My understanding was that lung cancer is payable for PET. I would reach out to the carrier to ask which LCD applies and review that.
 
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