Oncology & Hematology Coding Alert

Answer: Performing 78803 (Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging) and 78804 (…planar, whole body, requiring 2 or more days imaging) together is a very normal part of nuclear medicine. Very often, a radiation oncologist will perform 78804 to determine whether a radiopharmaceutical such as Zevalin or Bexxar should target a patient’s tumor or a critical organ; after, the oncologist will perform a further single photon emission computed tomography (SPECT) study (the 78803) with a 3-D reconstruction of the 78804 for further detail.

The codes are not subject to any National Correct Coding Initiative (NCCI) pair-to-pair (PTP) edit, and so can be billed separately with no modifier needed. However, some payers may require you to use modifier 51 (Multiple procedures).

Expert coding tip: Modifier 51 reduces payment for a service in half. Consequently, if your payer does require you to use the modifier when billing for both procedures together, you should append it to the lower-paying code. When billing globally, the nonfacility fee for 78803 is $397.08, while the nonfacility fee for 78804 is $677.62.

However, if you are billing for the professional component only with modifier 26 (Professional component), the 51 may need to be placed on the 78804, as this is the lesser reimbursed code/ service ($48.15 as opposed to $51.29 for the 78803). Check your locality amounts to determine when or if a modifier 51 is applicable and to which code it should be appended.