CASE STUDY:
Arm Yourself to Solve Tough PET/CT Reports With This Expert Insight
Published on Mon Feb 26, 2007
Find out when coding a separate CT is above-board PET/CT machines offer radiologists improved images, and good documentation of these services needs to be just as full of information. Here's a look at a report with real-life problems with tips on how to solve them. Determine What's Missing From This Report PET/CT skull base to mid-thigh
Fasting blood sugar at the time of injection was 96. Imaging performed 50 minutes post injection on the GE Discovery LS Hybrid PET/CT scanner with CT attenuation correction. Images reviewed in axial, coronal, and sagittal planes. 3D reconstructed model of the whole body was obtained and submitted for interpretation.
Findings: Whole-body PET/CT hybrid images show no focal increased metabolic uptake to indicate metastatic disease. Specifically there is no abnormal uptake seen in the small bilateral lung nodules seen on CT examination [date deleted]. No abnormal uptake in the mediastinum to suggest nodal metastatic disease. In the neck, there is physiologic uptake but no evidence of metastatic disease.
In the abdomen and pelvis, there is physiologic uptake seen in the GI tract in the left colon extending to the rectosigmoid. There is also physiologic uptake in these structures. No evidence of metastatic disease identified.
Impression: Negative whole-body PET/CT hybrid examination. No evidence of metastatic disease on this examination. CPT: Compare the Header and Findings/Impression The correct CPT code for this report is 78815 (Tumor imaging, positron emission tomography [PET] with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization; skull base to mid-thigh), says Lori Hendrix, CPC, CPC-H, coding consultant with Coding Strategies Inc. in Powder Springs, Ga.
What's right: The physician documented the procedure and scanner type clearly, Hendrix says.
What's wrong: The header says, "PET/CT skull base to mid-thigh," but the Findings and Impression say, "whole-body PET/CT hybrid images," she says.
You should never code a report based on the header, but in this case you can't accept the Findings' or Impression's claim of "whole-body" automatically either.
The documentation does not support coding a whole- body scan, Hendrix says.
The radiologist discusses the lungs, the mediastinum (in the chest), the neck, and the GI tract in the abdomen and pelvis (left colon to rectosigmoid). Discussion of these structures supports coding a skull base to mid-thigh PET/CT (77815) rather than a whole-body PET/CT (78816, ....whole body).
Tip: Typically only melanoma patients receive whole- body scans, Hendrix says.
Another coding option to consider is 78814 (... limited area [e.g., chest, head/neck]). But because the radiologist documents findings in more than one limited area, you know that 78815 is the right choice. ICD-9: Verify Diagnosis Before You Code Although the procedure documentation is adequate, documentation of clinical history is completely missing from this report, meaning you have no way to know why the [...]
