Oncology & Hematology Coding Alert

Get the facts before joining the office-owned PET machine trend

PET scans offer a great tool for tumor imaging, and technology is improving all the time. Two promising options are 3D reconstruction and PET/CT machines--but the latest National Correct Coding Initiative edits prove you need to watch your step before reporting codes for these services on the same claim.

Distinguish PET, CT, and PET/CT

Red flag: Don't report 78814-78816 (Tumor imaging, positron emission tomography [PET] with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization ...) if the physician performs a PET and a separate CT, says Denise Merlino, CNMT, MBA, FSNMTS, coding and reimbursement adviser to the Society of Nuclear Medicine.

Only use codes 78814-78816 to report studies on machines designed to perform a PET with a concurrent CT done for attenuation correction (producing a more defined PET with better images).

If you have documentation of a PET/CT along with a diagnostic CT, don't assume you can't report the diagnostic CT.

How to do it: Be sure you have a separate order for the diagnostic CT and proof of medical necessity before you code it. You may need to add modifier 59 (Distinct procedural service) to the CT code to tell the payer you performed two separate services.
 
Watch out: Coders often misuse modifier 59. Only append 59 if the two procedures are performed at separate sites or at separate patient encounters on the same date of service.

Caution: If the documentation shows a diagnostic CT on a PET/CT machine that automatically creates a PET/CT image, don't report 78814-78816 for the diagnostic CT, experts say.

Follow NCCI or Face 76375 Denials

The latest NCCI edits, effective Oct. 1, bundle 3D reconstruction into certain PET and PET/CT codes, so don't take chances when you report 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computed tomography, magnetic resonance imaging, or other tomographic modality) with 78811-78813 (Tumor imaging, positron emission tomography [PET] ...) or 78814-78816 (PET/CT).

The new edits cite coding manual instructions as the reason for the bundle. CPT Changes 2005 offers a detailed description for PET/CT code 78814. One key phrase explains that 78814 includes -acquisition and reconstruction of the PET data in multiple planes.- Code 76375, of course, represents multiplanar reconstruction. Translation: Reporting a PET/CT code alongside 76375 would claim reconstruction twice.

Benefit From Past 76375 Discussions

Auditors and professional groups have been debating the proper rules for reporting 76375 for some time now. Many experts agree that you should verify that the service is medically necessary and appropriately documented, and  always have the physician dictate why the reconstruction needed to be performed. If you code reconstruction routinely (with all or most of your exams), you may be setting yourself up for an audit. 

Try this: Clearly state the medical reason for the reconstruction in any plane(s) other than the original images- plane. Discuss the necessity of these reconstructed images with the referring physician and document that discussion in the report, especially if these additional reconstructions do not appear in the referring orders.

Tip: Pay attention to the descriptor to see how the American Medical Association intends you to use 76375. You can report 76375 in addition to routine CT, MRI or other tomographic modality procedures when the radiologist uses coronal, sagittal, multiplanar, oblique, 3D and/or holographic reconstruction techniques.

Avoid These 2 Common 76375 Pitfalls

Pitfall 1: Don't forget that 76375 applies to -other tomographic imaging,- says Bruce W. Hammond, CRA, CNMT, COO of Diagnostic Health Services in Texas. This imaging could include nuclear medicine studies, he adds. Smart: Take the time to learn about imaging processes and ask imaging personnel for the specifics to boost your coding accuracy, he says.

Pitfall 2: You shouldn't report 76375 for CT/MRI imaging procedures physicians perform in the coronal, sagittal, multiplanar and/or oblique planes. Instead: You should only use this code to report studies that have been reformatted from one plane into another.

Absorb Cost of Injection, not Agent

Payers differ on whether you may report FDG with your PET or PET/CT, so check your payer guidelines to be sure. In general, if your payer doesn't offer specific instructions on whether to report FDG, it's a good idea to code it. Why: Reporting the FDG use helps the payer (especially CMS) collect data on what's involved with PET procedures.

What to do: If you code for a physician or independent center, report A4641 (Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified). For OPPS, you should report C1775 (Supply of radiopharmaceutical diagnostic imaging agent, fluorodeoxyglucose f18, per dose).

Don-t: Just because you can report FDG doesn't mean you can report an injection procedure, so leave that injection code off of your PET claim.

The guidelines for the 2006 injection codes discussed in -Banish G Codes in Place of More Specific Antineoplastic and Initial Infusion Codes- explain not to use the diagnostic injection and infusion codes when it's an inherent part of the procedure, such as administering contrast material for a diagnostic imaging study.