Oncology & Hematology Coding Alert

Question: I am having problems getting reimbursed for a CT scan of the brain without and with contrast, 70470, when the oncologist has indicated lung cancer, 162.8, as the reason for ordering the test without showing any symptoms or signs of brain cancer. How do we get these paid by Medicare and other carriers?

California Subscriber

Answer: You may not get paid, unless you receive prior authorization. The hesitancy to pay is a result of differing medical opinion. Lung cancers often metastasize to the brain, liver, adrenals, bone and kidneys, but evaluation of these organs is usually directed by symptoms and clinical suspicion rather than by routine scanning. Frequently when the chest CT scan (71275) is obtained it may be continued at least through the adrenals, if not through the entire liver. Although the presence of distant metastases affects the long-term prognosis of the patient, there are those who believe full body evaluations should not be done.

Getting pre-approval is the best way to ensure reimbursement. This gives you an opportunity to respond to any questions or concerns of the insurer. This is especially important in any tests or procedures that can be controversial. Be sure to document your discussions and ask for the response to be faxed to you so you have a paper trail. Approval for procedures, tests and treatments may require that supporting documentation such as articles or abstracts be sent to the insurer and/or a discussion be held between the oncologist and plans medical director.