Basics of PET scan CPT code 78815 & 78816

PET scan CPT code (Positron emission tomography) is coded very frequently in Radiology facility coding. PET scan is done to diagnose a condition or to check how condition is developing. Neoplasm can be in there initial stage or Restaging phase. These exams are not painful. PET exams help in diagnosing cancer, heart disease and epilepsy. The best advantage of PET stage compared to CT or MRI is it can tell how the patient’s body is functioning rather than just how it looks. We are here just to learn the different modifiers used with PET scan CPT code used for initial and restaging. In medical coding, CPT code 78815 & 78816 are used mostly commonly for PET/CT scan procedures.

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Modifiers for PET scan CPT code 78815 & 78816

Two modifiers PI and PS are used with PET scan CPT codes. These Modifiers are used to denote whether the disease is at initial or Restage. The study is mostly on cancer cells. The two modifier used are PI (initial staging) and PS (Restaging). There are few PET scan CPT Codes used for coding. Below are the CPT codes.

78608 – Brain imaging, Positron emission tomography (PET); metabolic evaluation

78811– Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)

78812– Positron emission tomography (PET) imaging; Skull base to Mid-thigh

78813– Positron emission tomography (PET) imaging; Whole body

78814– Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)

78815– ; Skull base to Mid-thigh

78816– ; Whole Body

G0219 PET imaging whole body; melanoma for non-covered indications

G0235 PET imaging, any site, not otherwise specified

G0252 PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)

Cpt Codes are divided as limited, skull base to mid – thigh and whole body. There is PET scan CPT Code with CT as well from 78814-16. These exams help for in getting good results. PI and PS modifiers are used with all these PET scan CPT code. It’s easy to differentiate between these codes and easy to code as well.

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Use of PI and PS modifier with PET Scan CPT code 78815 & 78816

Q0 – Investigational clinical trial service provided in a clinical research study that is in an approved clinical research study.

HCPCS modifier Q0 is no longer required for services performed on and after June 11, 2013.

PI – PET or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.

PS – PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy.

 Each different cancer diagnosis is allowed one initial treatment strategy PET scan (with HCPCS modifier PI) and three subsequent treatment strategy PET scans (with HCPCS modifier PS). PET scans for subsequent treatment strategy (with HCPCS modifier PS) for the same cancer diagnosis (number four or more) require HCPCS modifier KX.

Initial staging PI modifier is added when there are signs of growth of cancer disease. For example, lung nodule, chest mass, bone lesion etc. When we have such indications for PET scan, we should use PI modifier with PET scan cpt code. For Restaging PS modifier, the report mostly mentions Restaging in the indication. But, if there is no mention of Restaging, one can check any comparison of PET given with the report. If there is a comparison given for PET report done previously we can go ahead and give PS modifier for PET scan. Since, earlier exam of PET suggest the presence of initial stage previously. So, now it is again restaging. If there is no comparison, we can blindly code PI modifier with PET scan CPT Code.

Effective for claims with dates of service on and after January 1, 2018, MACs will ensure when PET tracer code A9597 or A9598 are present on a claim, that claim must also include:

• An appropriate PET HCPCS code, either 78459, 78491, 78492, 78608, 78811, 78812, 78813, 78814, 78815, or 78816
• If tumor-related, either the -PI or -PS modifier as appropriate
• If clinical trial-, registry-, or study-related outside of NCD220.6.17 PET for solid tumors, clinical trial modifier -Q0
• If Part A outpatient and study-related outside of NCD220.6.17 PET for solid tumors, also include condition code 30 and ICD-10 diagnosis Z00.6
• If clinical trial-, registry-, or study-related, all claims require the 8-digit clinical trial number

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PET Radiopharmaceuticals
• FDG
[F-18]fl uoro-2-deoxy-D-glucose (FDG) is an analog of glucose and localizes in high concentration
in some normal tissues (heart, brain, and liver) and most malignant tumors. Use of this imaging
technique in oncology is based on the observation that malignant tissues have a higher uptake of
FDG than do the surrounding normal tissues.
• NaF
[F-18] sodium fl uoride (NaF) is a positron-emitting boneseeking agent that localizes in high
concentration in the skeleton. Its uptake mechanism resembles that of Tc-99m MDP. After
intravenous administration, [F-18]fl uoride ion diffuses through the capillaries into the bone
extracellular fl uid.
• [F-18]fl orbetapir
[F-18]fl orbetapir (AV-45, Amyvid®) is a small molecule stilbene derivative that binds selectively to
human -amyloid neuritic plaques with nanomolar affi nity. The brain uptake of fl orbetapir refl ects the regional density of neuritic plaques measured at autopsy

Sample chart for PET scan CPT code 78815 & 78816

CPT 78815-PI

INDICATION: Carcinoma of unknown primary

PET CT SKULL BASE TO MID THIGH

HISTORY: Carcinoma of unknown Primary

COMPARISON: Chest CT from 01/18/2010.

TECHNIQUE: Prior to administration of F18-fluorodeoxyglucose (FDG), the fasting glucose level measured by the glucometer was 107 mg/dL. Approximately one hour after the intravenous administration of 16.2 mCi of F18-FDG and oral administration of contrast, emission PET images of the body were obtained from the skull base to the mid thigh. Non- contrast CT images were obtained for attenuation correction and are not of diagnostic quality and are not used to diagnose disease independently of the PET images.

Findings:

Head/neck: No foci of abnormally increased FDG metabolism.

Chest: A focal area of increased FDG metabolism corresponding to distal esophagus, SUVmax 5. 8. Abdomen/pelvis: No foci of abnormally increased FDG metabolism.

Osseous structures: Multiple foci of abnormally increased FDG metabolism are noted in the visualized osseous structures including the skull base, SUVmax 10.2, right lateral mass of C2, SUVmax 14.9, posterior and lateral right rib, SUVmax 9.8 and 14.8, respectively. Expansile lytic lesion in the right lateral 2 nd rib, SUVmax 14. 8. Posterior left fourth rib, SUVmax 11. 8. T4 vertebral body, SUVmax 11. 8. Multiple additional areas of increased FDG metabolism is noted in the visualized osseous structures. Low dose CT scan was performed for attenuation correction and localization purposes. Review of the low-dose CT scan demonstrates calcified atherosclerosis in the aorta. There is thickening of the distal rectum, although no high metabolic activity is noted on the PET portion of the exam.

IMPRESSION: Multiple hypermetabolic lytic lesions involving the visualized osseous structures. There is near complete destruction of the T4 vertebral body. A tiny focus of increased FDG metabolism in the distal esophagus may be physiologic although a small neoplasm cannot be excluded with certainty.

Reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10319.pdf