Radiology Coding Alert
Tackle the Logistics of Initial, Subsequent PET Scan Coding
Put equal consideration into the CPT® and ICD-10-CM portions of the visit. In Radiology Coding Alert Volume 22, Number 4, you broke down some of the fundamental components of positron emission tomography (PET) scan billing. Today, you’re going to put what you’ve learned into practice by chronicling and coding a series of patient PET scan encounters over an extended period of time. In order to get every piece of this coding puzzle in place, you’ll have to maneuver between various aspects of the dictation report and the knowledge accrued along the way. Plus, you’ll have the added task of supplying the correct set of ICD-10-CM codes. Polish off your skills by working your way through the following interrelated PET scan scenarios. Consider When to Bill PET Scans Globally Scenario 1: Initial PET scan Indication: Staging of non-Hodgkin’s lymphoma. Technique: 10.4 mCi of FDG was injected. Delayed whole body fusion PET/CT scan is performed in 3 planes from the skull base to the mid-thighs. Impression: Large right supraclavicular/infraclavicular hypermetabolic mass with 2 smaller hypermetabolic lymph nodes as described in neck. Multiple mildly enlarged hypermetabolic retroperitoneal lymph nodes. Before you dive into the coding mechanics, you should make a habit of checking a PET scan patient’s chart to confirm whether the PET scan you’re coding is an initial or subsequent scan. Each unique cancer diagnosis is allowed one initial treatment strategy PET scan using modifier PI (Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing). For subsequent related scans, you’ll append modifier PS (Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy). If the patient has a PET scan at a later date for an unrelated cancer diagnosis, you may append modifier PI to the initial scan code. The technique documents a fusion PET/CT scan performed from the skull to mid-thighs. This means you’ll report CPT® code 78815 (Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh). Remember not to confuse the “whole body” terminology with a whole-body PET scan code. You’ll want to base your code selection on the extent of the body (or specific anatomic site) scanned. Next, you’ll report code A9552 (Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries) for the radiopharmaceutical tracer. Lastly, do not forget to include modifier 26 (Professional Component) for providers performing the interpretation, only. Coder’s note: If you code for a radiology practice that almost exclusively performs the professional component (PC) portion of the scans, don’t necessarily make the same assumption for PET scans. “You’ll find that many radiology practices establish a contract with an outside vendor to utilize mobile PET scan equipment on a monthly, or biweekly, basis,” details Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “The contract between radiology practice and vendor gives the radiologist, or group, ownership of the PET scan equipment during the time of use. Therefore, you should code the PET scan globally,” explains Rosenberg. Lastly, you’ll report code C85.91 (Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck) for the diagnosis of non-Hodgkin’s lymphoma. If you’re unfamiliar with PET scan coding, more often than not you’ll encounter diagnostic scenarios such as the one outlined in this example. The radiologist will indicate a definitive malignancy diagnosis in the indication and subsequently relay the degree of hypermetabolic activity of the malignancy in the impression. You may also have to combine information from the indication and impression to form a whole diagnosis. Ideally, you’ll want the radiologist to indicate in the impression or the findings that the hypermetabolic mass corresponds to the known malignancy, but the detail the physician provides in this example is technically sufficient to correlate the hypermetabolic mass to the non-Hodgkin’s lymphoma. Append Correct Subsequent Scan Modifier Scenario 2: Follow-up PET scan two months later Indication: Large cell lymphoma. Technique: 8.8 mCi of FDG was injected into the right upper extremity. Whole body fusion PET/CT is performed in 3 planes from the skull base to the mid-thighs. Impression: Large right supraclavicular mass. Compared to the initial PET, this has decreased in size and markedly decreased in metabolic activity. Persistent small focus of hypermetabolic activity in the left upper neck deep to the masseter muscle. This follow-up PET scan closely resembles that of the patient’s initial scan two months prior. While you will be reporting the same CPT® code (78815) and radiopharmaceutical tracer code (A9552), you’ve got to take some other variables into consideration. First, you’ll append modifier PS to 78815 to indicate that this is a subsequent scan. You’ll notice a change to the diagnostic portion of the dictation report as well. The indication now reveals a slightly more specified type of non-Hodgkin’s lymphoma as a diagnosis — large cell lymphoma. However, you don’t have enough documentation to support a diagnosis other than C85.91. Do not make the error of assuming B-cell lymphoma and reporting code C83.31 (Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck). Don’t Mistake Lack of Hypermetabolic Activity With Hx Diagnosis Scenario 3: A second follow-up PET scan one year later Indication: Staging of lymphoma. Technique: 11.8 mCi of FDG was injected into the left upper extremity. Fusion PET/CT scan is performed in 3 planes from the skull base to the mid-thighs. Impression: No evidence of persistent hypermetabolic neoplastic activity or lymphoma. Hypermetabolic activity corresponding to the left masseter muscle. This was also demonstrated on the prior PET scan. There is no associated mass. Your CPT® and HCPCS coding will go as follows (depending on use or non-use of modifier 26): The hang-up once again comes with respect to the diagnosis portion of this PET scan. As you can see, based on the prior exams, the specificity of the lymphoma has actually regressed back to unspecified levels. While an unspecified diagnosis of “lymphoma” qualifies as C85.90 (Non-Hodgkin lymphoma, unspecified, unspecified site), it may be worthwhile to send this report back to the provider for a more descriptive addendum. That’s in part because, as the impression outlines, there’s no identification of the anatomic location of the patient’s previous non-Hodgkin’s lymphoma of the neck diagnosis. If the findings offer further elaboration as to the location of the (eradicated) malignancy, an addendum is not necessary. Coder’s note: Just because the impression does not indicate any remaining traces of hypermetabolic activity in the area corresponding to the patient’s non-Hodgkin’s lymphoma, you should still report a current malignancy diagnosis until the provider includes a “history of” diagnosis.
Radiology Coding Alert
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Tackle the Logistics of Initial, Subsequent PET Scan Coding
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