Radiology Coding Alert

Your ICD-9 lymphoma options have already changed, and CPT has PET scan code changes in store for 2008. Here's what you need to know when you report your next lymphoma PET scan.

In 2007, you probably turned to 202.80 (Other lymphomas; unspecified site, extranodal and solid organ sites) for many of your lymphoma claims, but you have multiple new options as of Oct. 1:

• marginal zone lymphoma (200.30-200.38)
• mantle cell lymphoma (200.40-200.48)
• primary central nervous system lymphoma (200.50-200.58)
• anaplastic large cell lymphoma (200.60-200.68)
• large cell lymphoma (200.70-200.78)
• peripheral T-cell lymphoma (202.70-202.78).

Reporting unspecified code 202.80 less often is a benefit, but all of these new lymphoma codes may cause some problems of their own, says Erin Goodwin, CPC, CMC, reimbursement and coding professional with a South Carolina clinic.

- What to watch for: Documentation must offer the details you need to choose among these new codes. The trick is finding the middle ground between the physician not documenting enough information and making his documentation so specific that you have a hard time choosing the most appropriate diagnosis code, Goodwin says.

- What to do: Once you get the final list of new codes, give your providers a job aid with the more specific codes, Goodwin says. Your physicians may not know what information you need for each diagnosis, so you can show them the detail you need and point out that documenting those specifics helps you do your job more efficiently and helps satisfy payers when they ask for medical records, she says.

- The provider's documentation should offer enough detail to allow you to choose among the following fifth-digit options:

• 0 -- unspecified site, extranodal and solid organ sites
• 1 -- lymph nodes of head, face and neck
• 2 -- intrathoracic lymph nodes
• 3 -- intra-abdominal lymph nodes
• 4 -- lymph nodes of axilla and upper limb
• 5 -- lymph nodes of inguinal region and lower limb
• 6 -- intrapelvic lymph nodes
• 7 -- spleen
• 8 -- lymph nodes of multiple sites.-

PET and PET/CT codes 78811-78816 will no longer include the phrase "tumor imaging" effective Jan. 1, but you should still use these codes for lymphoma PET imaging.

2007 codes: Now you choose from the following CPT codes:

• 78811 -- Tumor imaging, positron emission tomography (PET); limited area (e.g., chest, head/neck)

• 78812 -- ... skull base to mid-thigh

• 78813 -- ... whole body

• 78814 -- Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (e.g., chest, head/neck)

• 78815 -- ... skull base to mid-thigh

• 78816 -- ... whole body.

2008 codes: For services on or after Jan. 1, the descriptors for these codes change to eliminate the tumor imaging language:

• 78811 -- Positron emission tomography (PET) imaging; limited area (e.g., chest, head/neck)

• 78812 -- ... skull base to mid-thigh

• 78813 -- ... whole body

• 78814 -- Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (e.g., chest, head/neck)

• 78815 -- ... skull base to mid-thigh

• 78816 -- ... whole body.

Rationale: Removing the phrase "tumor imaging" doesn't mean that you should no longer use these codes for tumor imaging. Instead, removing the phrase allows the use of these codes for additional types of services. In particular, the Society for Nuclear Medicine (SNM), the American College of Radiology (ACR) and the Academy of Molecular Imaging (AMI) have all written to CMS to support covering FDG-PET for infection and inflammation.

Reality: "Just because the word 'tumor' is removed doesn't mean CMS is going to change coverage," says nuclear medicine coding expert Denise Merlino, CPC, CNMT, MBA, FSNMTS, president of Merlino Healthcare Consulting Corp. in Stoneham, Mass. CPT 2008 removes the word "in anticipation of potential changes in coverage, or for private payers who might choose to cover other procedures," she says.

Now that you know the new codes, try applying them to this example.

Example: Following a course of chemotherapy, a physician orders a restaging skull base to mid-thigh PET/CT for a patient with head and neck marginal zone lymphoma. The patient has the scan 56 days after his last PET/CT. The ordering physician wants to detect any residual disease.

Solution: You should report 200.31 (Marginal zone lymphoma; lymph nodes of head, face and neck) and 78815. For services on or after Jan. 1, your coding will remain the same despite 78815's code descriptor change.

Remember: You should report PET/CT codes only for scans performed on equipment designed to take PET and CT images concurrently for attenuation correction. You shouldn't report this code if the radiologist combined PET and CT scans performed on different machines.

Resource: CMS offers a national coverage determination (NCD) for FDG PET lymphoma in the NCD manual, chapter 1, part 4 (section 220.6.5) at http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf.