Wiki Pet scan nightmare!!!!!

[mzblackmon12@gmail.com]

We are a billing company that does coding for the radiology dept of the hospital...so we are not doing hospital billing...I said that to say the hospital is gettign paid on these PET scans using the same dx.. but we cant seem to get them paid...example..first scan 78815 PI M26 pt has history of prostate cancer & bladder cancer in the report there was evidence of retroperitoneum malignant neoplasm...unknown if biopsy proven. so dx codes are as follows;
197.6, v10.46, 188.9 V71.1...then pt had another scan done 3 months later
78815 PS M26 dx 188.9 v10.46 793.11 v71.1
3 months later 78815 PS M26 188.9 v10.46 v10.51 197.6

None of them have paid...can someone please tell me what we are doing wrong..MCR keeps saying the dx are not covered but everything that I research says that each dx is a covered dx......we are stuck!
Thank you!

 

[BJTRAISTER]

Assuming you have checked your Medicare LCD's and the diagnosis you are using are covered I would send an appeal to the FI or contact them via phone if possible to find out what the issue is and quote the LCD that you are referencing.

 

[rfowler5]

I would make sure modifier pi or ps is after modifier 26 after the cpt codes. Sometimes order of modifier matters.

 

[LScottCPC]

Medicare only covers restaging of bladder cancer and prostate cancer (called coverage with evidence development or CED) if they go thru a clinical trial called the National Oncologic PET Registry or NOPR. Once all of the paperwork is back from the referring doctor, it has to be billed with a PS and a Q0 (zero) modifier to signify it is part of the clinical trial, if its a Medicare Advantage plan, the Q0 must go on the A9552 or A9580 (for Sodium Fluoride bone PET) as well. If you have any other questions, I will try to answer them for you. I do precertifications and coding for 4 PET centers.