Coding Corner: Feeling Shaky About Reporting PET Scans for Cancer Patients?

Put payment on solid ground with a crash course

If you're submitting PET scan claims for cancer patients without knowing the difference be-tween public and private payers' rules, you can bid your reimbursement farewell.
Physicians use positron emission tomography (PET) scans to assess metabolic function for several purposes - to find the source of various cancers and determine the aggressiveness of the tumor, to detect abnormalities in brain functioning, and to analyze heart tissue, including ruling out coronary artery disease. While both Medicare and private payers reimburse you for most of these functions, different payers require different codes.
Identify the Payer
"Different payers have different guidelines," says Melody Mulaik, MSHS, CPC, CPC-H, with Coding Strategies Inc. in Atlanta, who presented on PET scan coding at the American Academy of Professional Coders annual conference. And although  most private payers usually follow Medicare's lead, you won't find many private carriers that are in alignment with Medicare's PET scan policy.
Medicare requires certain G codes that describe the type of test, such as G0210 (PET imaging whole body; diagnosis; lung cancer, non-small cell). Private payers, however, require codes from the 78000 series (radiology), such as 78810 (Tumor imaging, PET, metabolic evaluation).
Keep in mind that many private insurers require precertification for PET exams, says Sharon Dargay, CPC, CPC-H, BS, RDMS, RT (R)(M)(QM), administrative manager of radiology at Crozer Chester Medical Center in Upland, Pa. The insurer will want to know why you're performing the scan so it can preauthorize the procedure. This process, Dargay says, "is basically an attempt at controlling utilization of certain procedures."
Mulaik says Medicare covers PET scans in certain situations for eight types of cancer: Non-small cell lung, esophageal, colorectal, lymphoma, melanoma, head/neck, breast, and thyroid.
Distinguish Between Diagnosis and Staging
The HCPCS manual divides PET scan codes between diagnostic and staging procedures, so you have to know whether the physician used the PET scan for diagnosing, staging, or restaging a cancer.
For instance, if the physician used a whole-body scan to diagnose a patient's lymphoma, you could assign G0220 (PET imaging whole body; diagnosis; lymphoma). On the other hand, if the physician ordered the scan for a restaging of the lymphoma, you would use G0222 (... restaging; lymphoma).
Heads-up: Generally, you'll have an easier time convincing a Medicare intermediary to pay for a staging code than a diagnostic one, because the payer considers staging and restaging as the PET scan's primary purposes.
Reimbursement reality: Medicare covers PET scans only in clinical situations in which the physician can use the results to avoid an invasive diagnostic procedure, or when the result can help [...]

- Published on 2004-08-23