Oncology & Hematology Coding Alert

Question: I received a Medicare claim rejection for 78816-PI, citing inconsistent modifier or required modifier is missing.

The physician order reads, “72-year-old male with high-risk prostate cancer, Gleason 9, needing imaging to assess for metastases. The purpose of this scan is for initial anti-tumor treatment strategy, initial staging.” The primary diagnosis listed on the claim is C61.

I reviewed the CMS Billing and Coding policy, which says claims for FDG PET or imaging for oncologic indications for initial treatment strategy must include the PI modifier. Claims for FDG PET imaging for oncologic indications for subsequent strategy must include the PS modifier.

When I run the codes through a scrubber (78816-PI with diagnosis C61) I get an error that tells me code 78816 doesn’t meet “the associated Modifier Code relationship criteria for CMS ID(s) 220.6.17.” When I change the modifier to PS the claim comes up clean.

Am I not supposed to bill modifier PI with a cancer diagnosis?

AAPC Forum Participant

Answer: Your coding of this encounter is correct. Using 78816 (Positron emission tomography (pet) with concurrently acquired computed tomography (ct) for attenuation correction and anatomical localization imaging; whole body) with modifier PI (Positron emission tomography (pet) or pet/ computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing) and diagnosis code C61 (Malignant neoplasm of prostate) accurately reflects the encounter you describe, as the provider ordered the PET scan for the initial treatment strategy.

As such, you would not use modifier PS (Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy) for this encounter. You’ll use PS to indicate a PET scan was for subsequent treatment strategy purposes, which did not happen in this case.

The reason the scrubber allows the PS modifier is due to the Medicare National Coverage Determination (NCD) you cite. NCD 220.6.17, section 2.C.1a, states “CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate” (www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=331&ncdver=4&bc=0). In other words, Medicare will cover PET scans in cases of subsequent treatment strategy purposes for patients with prostate cancer (modifier PS), but not in cases of initial treatment strategy purposes for patients with prostate cancer (modifier PI).

So, in this encounter, a PET for initial treatment strategy of the prostate is noncovered for Medicare, which is why 78816-PI is denied. If the physician feels this is necessary, you will need to deliver an advanced beneficiary notice (ABN) to the patient explaining it is not covered if elected.