Radiology Coding Alert

CCI says you can bill both, but here's the reality.

Physicians may order multiple imaging exams in a single day for a patient with cancer. Here are some aspects to consider before submitting your next claim.

Consider This PET/CT + CT Scenario A Radiology Coding Alert reader asked: A patient has a PET/CT (78815, Positron emission tomography [PET] with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging; skull base to midthigh) for lung cancer (162.3, Malignant neoplasm of upper lobe bronchus or lung) in the PET/CT suite in the Nuclear Department. Later the same day this patient goes to the CT suite and has a chest CT with contrast (71260, Computed tomography, thorax; with contrast material[s]) and abdominal/ pelvic CT with contrast (72193, Computed tomography, pelvis;  with contrast material[s]; and 74160, Computed tomography, abdomen; with contrast material[s]) to rule out metastasis from the lung cancer. Are the CPT codes for the CT exams and PET/ CT exam appropriate when all are performed on the same day?

See What the CCI Manual Says

You won't encounter Correct Coding Initiative (CCI) edits for these particular codes, but you may have some coverage issues to research. The short version is that you can bill both if they're both medically necessary, but most payers only pay for one, says Lori Hendrix, CPC, CPC-I, CPC-H, CIRCC, PCS, FCS, of Compass Coding Services in Hiram, Ga.

For Medicare patients, the CCI manual, version 16.3, chapter 9, section H.13, specifically states that you may report a "medically reasonable and necessary diagnostic CT scan" in addition to PET and PET/CT codes 78811-78816. So that includes 78815, which is the code in our scenario.

Warning: If the CT scan is for localization, you should not report the CT in addition to 78811-78816, the CCI manual states. Similarly, a note following 78814-78816 in the CPT manual states that you may report CT "performed for other than attenuation correction and anatomical localization" separately by appending modifier 59 (Distinct procedural service) to the appropriate CT code.

The bottom line is that you may have an uphill battle to prove that both the PET/CT and the CT scans were medically necessary.

Don't Forget to Check NCD Regarding ICD-9

You also should check coverage requirements for the patient's particular diagnosis, which in the scenario is 162.3 (Malignant neoplasm of trachea, bronchus, and lung; upper lobe, bronchus or lung).

The Medicare National Coverage Determination (NCD) for FDG PET for Solid Tumors and Myeloma shows that Medicare covers PET when used for initial treatment strategy for nonsmall cell lung neoplasms and small cell lung neoplasms.

For subsequent treatment strategy, Medicare covers PET for non-small cell lung, but lists small cell lung neoplasms under Coverage with Evidence Development (CED). CED means that not only does the ordering physician need to determine that the test is needed to inform the treatment strategy, but the beneficiary must be enrolled in and the PET provider must be participating in clinical studies that meet defined requirements (www.cms.gov/Transmittals/downloads/R120NCD.pdf).

Remember: Check for required modifiers. For services listed as CED, you'll need to append:

• modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study)

• either modifier PI (Positron emission tomography [PET] or PET/computed tomography [CT] to inform the initial treatment strategy of tumors ...) OR modifier PS (Positron emission tomography [PET] or PET/computed tomography [CT] to inform the subsequent treatment strategy of cancerous ...).

Bonus tip: You'll have new coding options for abdominal and pelvic CTs starting Jan. 1, so confirm the date of service before you choose your code.