Medicare Compliance & Reimbursement

Nuclear medicine services now included in PET imaging.

All doctors that perform PET tumor imaging may have to step more carefully around a new set of Correct Coding Initiative edits in October.

CCI 11.3 turns a number of nuclear medicine codes into components of PET tumor imaging codes 78811-78816. Physicians will be able to use a modifier to override the edits, but they'll have to justify billing for the nuclear medicine procedures separately.

The component codes for these edits include several codes for computed tomography scans: 70450, 70480, 70486, 70490, 71250, 72125, 72128, 72131, 72192, 73200, 73700 and 74150. Also, a component of the PET codes is CPT code 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of a computed tomography, magnetic resonance imaging, or other tomographic modality).

"The CT codes should not be reported with any of the tumor imaging PET CPT codes 78811-78816 if the CT is performed for anatomical localization or attenuation correction," the Centers for Medicare and Medicaid Services says in a June 22 letter to the American College of Radiology. But CMS adds that it's okay to bill for a separate diagnostic CT scan, as long as it's medically necessary, using the appropriate modifier.

Another set of edits involving the PET tumor imaging codes won't allow physicians to use a modifier to override them. These edits bundle the less extensive codes with the more extensive codes. So, for example, 78811-78815 are bundled with 78816, and 78811-78814 are bundled with 78815.

Surgeons billing for 20690 (Application of a uniplane [pins or wires in one plane], unilateral, external fixation system) may need a modifier to bill with more surgical codes. CCI Vol 8.0 bundled 20690 with over 200 surgical codes, and now CCI 11.3 makes 20690 a component of 37 more surgical codes. Physicians can no longer bill 20690 with several codes for capsulorrhaphy, arthrodesis, osteotomy, autograft, tumor resection, hand surgery, femur and knee surgery, and leg and ankle joint surgery.

The American Academy of Orthopedic Surgeons says that doctors shouldn't bill for 20690 with codes whose descriptors say "with external fixation." But a doctor should be able to bill for it with codes whose descriptors say with "internal or external fixation"--if she performs both internal and external fixation--because the code is only valued for one type of fixation. Be aware that the CCI edits seem designed to make these code pairs more difficult.