星空入口

Question: I am having terrible issues with referring doctors using R91.8 for 78815/A9552. In the past, I have been instructed not to accept this code. However, in just the past 3 weeks, I have had an increase of fluorodeoxyglucose (FDG) positron emission tomography (PET) scans being approved with this diagnosis code. I have some referring doctors upset that I have requested them to change the authorization, which is what our billing center advised me to do. 

星空入口Forum Participant

Answer: The advice you have been receiving from your billing center is incorrect. to justify medical necessity for 78815 (Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh) and A9552 (Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries) if contrast is used in the scan for locating oncological conditions.

The codes include R91.8 (Other nonspecific abnormal finding of lung field).

NOTE: Medicare鈥檚 national coverage determination (NCD) >220.6.17 states that Medicare will cover 鈥渙ne FDG PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary鈥檚 treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for 鈥� therapeutic purposes related to the initial anti-tumor treatment strategy.鈥� The NCD also states that 鈥渢hree FDG PET scans are nationally covered when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy.鈥� Additionally, 鈥渃overage of more than three FDG PET scans to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy shall be determined by the local Medicare Administrative Contractors.鈥�

This means you will need to add 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 the initial FDG PET scan or modifier PS (Positron emission tomography (PET) or PET/computed tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary鈥檚 treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy) for repeat scans.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC