Radiology Coding Alert

Change your ways, now that CMS has traded G codes for 78811-78816

If you use partial, full ring, or PET/CT equipment for tumor imaging, post this handy chart by your desk. You'll see at a glance which ICD-9 Codes many payers agree prove medical necessity for PET services.

Caution: This chart lists commonly accepted codes, but you should check your payer's policies - both for which codes to use and when to expect reimbursement. Medicare generally won't cover PET services for checking tumor progress, even if you report all the right codes, unless the restaging is used to detect a suspected recurrence, determine the extent of a known recurrence, or follows the completion of treatment and you're checking for residual disease. You can see CMS' National Coverage Determination on PET at www.2.cms.hhs.gov/manuals/pm_trans/R31NCD.pdf.

Note: Starting April 4, 2005, CMS decided it would no longer cover G codes for PET. Instead, report 78811-78813 (Tumor imaging, positron emission tomography [PET]...) or 78814-78816 (Tumor imaging, positron emission tomography [PET] with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization), which CPT Codes added in 2005. A Society for Nuclear Medicine crosswalk is at http://interactive.snm.org/index.cfm?PageID=3855&RPID=277; click on "PET: CPT to HCPCS Level II Crosswalk" at the bottom of the page. 

Don't forget: CMS announced expanded coverage, effective Jan. 28, 2005, for PET scans for newly diagnosed and locally advanced cervical cancer to detect pretreatment metastases when conventional imaging (such as CT or MRI) for extra-pelvic metastasis is negative. CMS will also cover PET for brain, ovarian, pancreatic, small cell lung, and testicular cancers if the patient and provider are enrolled in particular clinical studies. Check out CR 3471, at www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp, for more information.

Accurate coding: You may only assign the diagnosis your physician documents at the time he ordered and interpreted the test, even if the payer doesn't cover that code for PET.