Oncology & Hematology Coding Alert

Get the most out of initial and restaging scans

When you're reporting positron emission tomography (PET) scans, the radiation oncologist's reason for the scan and the patient's cancer will determine the codes you assign.

A PET scan is a noninvasive imaging procedure that assesses perfusion and various organs'metabolic activity. Your radiation oncologist uses the scan to detect breast cancers (174.x) and metastatic cancers (198.x), says Linda L. Lively, MHA, CCS-P, RCC, CHBME, founder and CEO of American Medical Accounting and Consulting in Marietta, Ga.

Medicare also covers PET scans for diagnosis, staging and restaging of various malignant neoplasms, including lung, esophageal, colorectal, lymphoma, head and neck and thyroid, she says.

Learn These Important PET Requirements

You should assign different oncology-related PET codes for private and Medicare insurers. Also, both sets of payers may have different coding and billing requirements.

For private carriers, you should report 78810 (Tumor imaging, positron emission tomography [PET], metabolic evaluation) for whole-body scans to determine the cancer's stage after a biopsy has revealed the malignant neoplasm, says Anita Perdue, CPC, billing office manager at Texas Hematology/Oncology Center PAin Carrollton, Texas.

Check with your local private carrier to determine which cancers the payer covers. For instance, Blue Cross Blue Shield in Carrollton, Texas, doesn't accept breast cancer codes (174.0-174.9) but pays for lung cancer (162.0-162.9), Perdue says.

Make Sure PET Scans Aren't Duplicates

On the other hand, if you want Medicare to pay for PET codes G0210-G0234, you have to meet the following requirements, according to Medicare guidelines:

The PET scan cannot unnecessarily duplicate other covered diagnostic tests. For instance, your radiation oncologist will use a PET scan when he is unsure of a cancer's stage following a standard diagnostic test, such as a magnetic resonance imaging (MRI) scan of the patient's stomach (74181, Magnetic resonance [e.g., proton] imaging, abdomen; without contrast material[s]). If the MRI reveals the cancer's stage, you probably shouldn't report a PET scan code.

Your practice should not bill for a PET scan that requires investigational drugs. Generally, your radiation oncologist will use 2-(fluorine-18)-fluoro-2-deoxy-d-glucose (FDG) for the scan. The appropriate code for FDG is A4641 (Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified). Most Medicare payers, however, won't pay for the code.

The physician must use a full- or partial-ring PET scan that the FDAhas approved.

Assign G Codes for Specific Cancers

Medicare has 25 oncology-related PET codes (G0210-G0234), many with different documentation and coding requirements. You can keep track of these codes if you understand how to link the G codes to the appropriate cancer, Perdue says.

That's because many PET codes represent different cancers, which means you have to ensure that the code you choose matches the type of neoplasm the physician examined.

"We require that the doctor document what stage of therapy the cancer is in so we can determine the code," Perdue says.

For example, the radiation oncologist orders a whole-body PET scan for the initial staging of neck cancer (195.0, Malignant neoplasm of other and ill-defined sites; head, face, and neck). Therefore, you could report G0224 (PET imaging whole body or regional; initial staging; head and neck cancer; excluding thyroid and CNS cancers).

Distinguish Between Diagnosis and Staging

The HCPCS manual divides PET scan codes between diagnostic and staging procedures. You have to know whether the physician used the PET scan for diagnosing or staging 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 carrier to pay for a staging code than a diagnostic one, because the payer considers staging and restaging as the PET scan's primary purposes.

Coverage: Medicare covers PET scans only in clinical situations in which the physician can use the results to avoid an invasive diagnostic, or when the result can help the physician determine how to perform an invasive diagnostic procedure, according to Medicare's Coverage Issues Manual. "In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are performed for the purpose of staging, not diagnosis."

Watch Out for Two Noncovered Codes

Just because Medicare creates codes, that doesn't mean you should expect Medicare to pay for them.

Medicare uses two PET scan codes primarily for tracking purposes, but will not pay for these services. These codes are 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]) and G0219 (PET imaging whole body; melanoma for noncovered indications).

Tip: You can easily weed out the noncovered codes, because they have color-coded instructions that designate them as "noncovered by Medicare."