PET/CT Coding Questions Answered
| New 2005 CPT® Codes: | |||
|
PET |
PET/CT | ||
| 78811 | Tumor imaging, positron emission tomography (PET); limited area | 78814 | Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area |
| 78812 | Tumor imaging, positron emission tomography (PET); skull base to mid-thigh | 78815 | Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh |
| 78813 | Tumor imaging, positron emission tomography (PET); whole body | 78816 | Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body |
PET/CT integrated system technology has evolved rapidly and continues to transform rapidly over time. Because the technology continues to change, there are many questions about how to use the new PET, PET/CT and established CT codes. The following Q&A will provide answers to some of the more commonly asked questions.
Background
Prior to 2005, tumor imaging positron emission tomography (PET) metabolic evaluation studies (excluding brain and cardiac) were identified by CPT® code 78810 for non-Medicare patients and by HCPCS Level II G codes for Medicare patients. In order to more accurately describe the work involved in these procedures and to replace the G codes used by Medicare with a more permanent coding structure, the CPT® coding structure had to be changed. Therefore, code 78810 was deleted, and three new PET codes were created in 2005 to describe: (1) a limited study (78811); (2) a skull base to mid-thigh study (78812); and (3) a whole-body (78813) study. In addition, three new codes were created (78814, 78815, and 78816) using this same structure to identify the new PET/CT technology being used, i.e., PET and CT performed concurrently at the same session on a PET/CT integrated system for attenuation correction and anatomic localization. No changes were necessary for the existing PET brain (78608, 78609) or PET myocardial imaging (78491, 78492) CPT® codes.
Q: What do the new 2005 PET/CT study codes (78814-78816) encompass?
The new 2005 PET/CT CPT® codes (78814-78816) were created to report a PET and CT concurrently obtained at the same session on a PET/CT integrated system where the CT portion of the study is co-registered with the PET images for the purpose of attenuation correction and anatomic localization. The PET/CT code assigned is based on the anatomical site studied, i.e., 78814 for a limited study (e.g., chest); 78815 for a skull base to mid-thigh study, or 78816 for a whole-body study.
Although some PET/CT integrated systems of today are capable of producing high quality diagnostic CT images, diagnostic CT studies should not be reported unless medically necessary and ordered by the referring physician.
Q: If a PET/CT and a diagnostic CT are performed on the same day, how are these studies coded?
If ordered by the referring physician as medically indicated, a PET/CT (where the CT is done for anatomic localization (AL) and attenuation correction) and a diagnostic CT may be reported for the same patient on the same day when a separate and distinct CT acquisition (data set) is performed. This third data acquisition for a diagnostic CT typically involves the administration of intravenous contrast material and potentially multiple CT data acquisitions in order to perform a complete diagnostic CT examination. The studies are coded as PET/CT (78814, 78815, or78816) + diagnostic CT(s) – 59. Coding for both the PET/CT and diagnostic CT would be appropriate because a different data set was acquired, interpreted and separately reported.
Due to continuing advances in PET/CT imaging equipment, when a PET/CT and a diagnostic CT are ordered, it may be possible to use the diagnostic CT data set for the attenuation correction and anatomic localization portion of the PET/CT study. When the physician is interpreting a diagnostic CT and anatomic localization of PET metabolic information from the same CT data set, the studies should be coded as a PET study plus a diagnostic CT study. The key distinction is that if both anatomic localization and diagnostic CT are accomplished from the same CT data set, then only a PET should be coded in addition to the diagnostic CT. The interpretation for the CT portion of a PET/CT study is reflected in the diagnostic CT CPT® code.
In certain cases, based on medical necessity, it is appropriate for a referring physician to order a diagnostic CT in addition to a PET/CT for the same patient on the same day. However, diagnostic CT is not required each time a PET study is ordered, even though the PET/CT integrated system is capable of producing a high-quality diagnostic image. Reporting of a diagnostic CT study when not ordered by the referring physician and not medically indicated would be considered unbundling. If a suspicious finding is seen on a PET/CT that should be evaluated with a diagnostic CT study, the nuclear medicine physician/radiologist should obtain an order from the referring physician for the appropriate diagnostic CT study. When diagnostic CT(s) is/are obtained at a separate session on the same day, either before or after the PET/CT was done, it is appropriate to code the PET/CT and diagnostic CT(s) separately.
Q: Who can make the determination that a PET/CT and a diagnostic CT are required?
Clinical necessity as evidenced by the referring physician order will determine if a diagnostic CT is indicated concurrent with a PET/CT examination. There should be ongoing communication among the nuclear medicine physician /radiologist and the referring physicians regarding PET/CT technology for the best care of the patients referred.
PLEASE NOTE:
While this is the ACR's current recommendation on how to code for PET/CT and diagnostic CT, it is recognized that the clinical indications and appropriateness involved in this new imaging technique is evolving rapidly. Thus the ACR Committee on Coding and Nomenclature will monitor this evolution closely and make future recommendations as appropriate.
Q: Should 3D rendering be reported separately in addition to PET and PET/CT procedures since 3D rendering is performed?
No, 3D rendering images should not be reported in addition to the PET and PET/CT codes. The 3D rendering is a basic component of all tomographic nuclear medicine studies (PET, PET/CT, SPECT) and the performance of reconstruction imaging has been valued into these codes, i.e., all PET scans were valued to include reconstructions in transaxial, sagittal, and coronal planes as well as 3D maximum intensity projection (MIP) images.
Q: Is a modifier required to be used when either PET or PET/CT for AL studies are performed on the same day as diagnostic CT study (ies)?
Yes, a modifier should be used when reporting PET or PET/CT codes with diagnostic CT studies. National Correct Coding Initiative (NCCI) edits will be implemented October 1, 2005 for the reporting of diagnostic CT and PET or diagnostic CT and PET/CT studies when performed on Medicare patients on the same day. When a diagnostic CT study is performed on the same day as a PET or PET/CT study, a modifier will be needed to distinguish these as separate and distinct procedures and not an attempt to unbundle a PET/CT study.
As noted in the CPT® 2005 code book, modifier -59 should be appended to the site-specific CT code when CT is performed for other than attenuation correction and anatomical localization. This will indicate to the payer that the CT is in fact a separately ordered diagnostic CT study.
Q: Do I use HCPCS Level II "G" codes or CPT® codes to report PET procedures?
Except for a handful of codes, the PET HCPCS Level II G codes have been inactivated and as of April 18 the "G" codes are no longer valid to describe PET studies. Please refer to the March/April 2005 ACR Radiology Coding Source™ for a complete list of G codes that have been inactivated and the new CPT® codes that have been established.
Although CMS noted in the 2005 Medicare Physician Fee Schedule that it would continue to use the "G" codes to report PET and PET/CT studies in 2005, CMS revised its position and issued Transmittal 475 (Change Request 3726, 2/11/05). This change was effective as of January 28, 2005 and carriers had until April 18, 2005 to implement this change. To see the First Update to the Medicare Physician Fee Schedule go to the CMS Web site at http://www.cms.hhs.gov/manuals/pm_trans/R475CP.pdf. Contact your local carrier/intermediary for any problems with claims for the period January 28 through April 17, 2005.
Q: Under what conditions does Medicare reimburse for PET studies?
Coverage of FDG PET is limited to dedicated full-ring detector technologies that are equal or superior in performance to selected high-performance PET scanners, as well as other scanners that have been approved or cleared for marketing by the FDA, and for certain coincidence systems as noted in CMS Transmittal 31, Section II (B) Pub. 100-03 at http://www.cms.hhs.gov/manuals/pm_trans/R31NCD.pdf. Check with your private payers to see if they follow these Medicare guidelines
The following is a listing of clinical conditions and PET systems approved for coverage by Medicare as of January 28, 2005:
| Covered Clinical Condition | Covered1 | Nationally2 Non Covered |
Coverage3 With Evidence Development* | Allowable Types of FDA PET Systems | |
| Solitary pulmonary nodule | Effective January 1, 1998 | -Characterization | FDA-approved full and partial ring, certain coincidence systems | ||
| Lung cancer (non-small cell) | Effective January 1, 1998
Effective July 1, 2001 Effective January 28, 2005 |
-Initial staging -Diagnosis, staging, restaging |
-Monitoring4 |
Certain coincidence systems FDA-approved full and partial ring | |
| Colorectal cancer | Effective July 1, 1999 Effective July 1, 2001 Effective January 28, 2005 |
Determining location of tumors if rising CEA level suggests recurrence
-Diagnosis, staging, restaging |
-Monitoring4 |
Certain coincidence systems FDA-approved full and partial ring | |
| Esophageal cancer | Effective July 1, 2001
Effective January 28, 2005 |
-Diagnosis, staging, restaging | -Monitoring4 |
FDA-approved full and partial ring | |
| Head and neck cancers (excluding CNS and thyroid) | Effective July 1, 2001
Effective January 28, 2005 |
-Diagnosis, staging, restaging | -Monitoring4 |
FDA-approved full and partial ring | |
| Lymphoma | Effective July 1, 1999 Effective July 1, 2001 Effective January 28, 2005 |
Staging and restaging only when used as alternative to gallium scan
-Diagnosis, staging, restaging |
-Monitoring4 |
Certain coincidence cameras FDA-approved full and partial ring | |
| Melanoma | Effective July 1, 1999 Effective July 1, 2001 Effective January 28, 2005 |
-Evaluating recurrence prior to surgery as alternative to gallium scan
-Diagnosis, staging, restaging |
-Monitoring4 |
Certain coincidence cameras FDA-approved full and partial ring | |
| Myocardial viability | Effective July 1, 2001 to September 30, 2002 Effective October 1, 2002 |
-Determination of myocardial viability only following an inconclusive SPECT
- Primary or initial diagnosis prior to revascularization |
FDA-approved full and partial ring | ||
| Perfusion of the heart using Rubidium 82* tracer | March 14, 1995 | -Noninvasive imaging of the perfusion of the heart | |||
| Perfusion of the heart using ammonia N-13* tracer | October 1, 2003 | -Noninvasive imaging of the perfusion of the heart | |||
| Refractory seizures | Effective July 1, 2001 | -Presurgical evaluation | FDA-approved full ring | ||
| Breast cancer | Effective October 1, 2002 | -Staging of distant metastases -Restaging, monitoring4 |
-Diagnosis -Initial staging of axillary nodes |
FDA-approved full and partial ring | |
| Thyroid cancer | Effective October 1, 2003 Effective January 28, 2005 |
-Restaging of recurrent or residual thyroid cancers of follicular cell origin | -Restaging of medullary cell tumors, -Diagnosis, other staging and restaging, -Monitoring4 |
FDA- approved full and partial ring | |
| Dementia and neurodegenerative diseases | Effective September 15, 2004 | Differential diagnosis of Alzheimer's disease with aberrant features vs fronto-temporal dementia | All other uses of FDG-PET for patients with a presumptive diagnosis of dementia-causing neurodegenerative disease | FDA-approved full and partial ring | |
| Cervical cancer | Effective January 28, 2005 | -Staging as adjunct to conventional imaging | -Other staging -Diagnosis, restaging, monitoring4 |
FDA-approved full and partial ring | |
| Brain, ovarian, pancreatic, small cell lung, soft tissue sarcoma, and testicular cancers | Effective January 28, 2005 | -Coverage with evidence development | FDA-approved full and partial ring | ||
| All other cancers not listed herein (all indications) | Effective January 28, 2005 | -Coverage with evidence development | FDA-approved full and partial ring |
1 = Covered nationally based on evidence of benefit. Refer to National Coverage Determination Manual Section 220.6 in its entirety for specific coverage language and limitations for each indication at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6&ncd_version=2
2 = Noncovered nationally based on evidence of harm or no benefit.
3 = Covered only in specific settings discussed above if certain patient safeguards are provided. Otherwise, noncovered nationally based on lack of evidence sufficient to establish either benefit or harm or no prior decision addressing this cancer. Medicare shall notify providers and beneficiaries where these services can be accessed, as they become available.
4 = Monitoring response to treatment when a change in therapy is anticipated.
*For cancer indications listed as "coverage with evidence development," the provider must be participating in, and patients enrolled in a prospective clinical study or registry that is designed to collect additional information at the time of the scan to assist in patient management. For a list of the covered indications, please refer to Appendix A of the CMS Decision Memo by clicking here.
For a detailed listing of the latest coding and billing requirements for FDG PET scans, see Pub 100-04, Medicare Claims Processing, Transmittal 527 (CR 3741) at the CMS Web site.
It is important that radiology practices issue an Advance Beneficiary Notice to patients receiving PET procedures to advise them that they may be responsible for payment if the specified conditions for PET coverage are not met.
Q: What are the payments one should expect for performing a PET or PET/CT study?
As noted in the Mar/Apr 2005 ACR Radiology Coding Source™ feature article titled New 78XXX Series CPT® Codes Replace HCPCS G Codes for PET Procedures, the technical and global components for PET studies are carrier determined. It is anticipated that both technical and global relative value units will be established and published for 2006. Professional component RVUs have been established for 2005 and a listing of the professional component RVUs can be found on the ACR Web site at http://www.acr.org/s_acr/doc.asp?CID=3467&DID=21312
As noted in the July 2005 Update of the Hospital Outpatient Prospective Payment System (HOPPS), CPT® codes 78811-78816 should be used in the HOPPS setting. PET codes 78811-78813 fall under APC group 1513, New Technology Level XIII, with a payment rate of $1150, while PET/CT codes 78814-78816 fall under APC group 1514, New Technology Level XIV, with a payment rate of $1250.
While there is approved "coverage with evidence development" through a clinical trial or registry, payment has not yet been implemented by Medicare carriers. Physician offices will not be reimbursed for the various PET services that specify "coverage with evidence development" until CMS publishes instructions to carriers, informing them of the implementation date and advising them how to reimburse this service. CMS indicated that this coverage decision will not be fully implemented until the clinical study and registry are operational and ready to accept enrollments. The ACR Radiology Coding Source™ will post updates regarding the handling of "coverage with evidence development" payments as they become available.
Q: What qualifications are required to read a PET/CT study?
Training qualifications to read a PET vs. CT study have been addressed by the American College of Radiology, Society of Nuclear Medicine and Society of Computed Body Tomography in a white paper to be published in the July 2005 Journal of the American College of Radiology. The purpose of the white paper is to define the issues surrounding implementation and use of PET/CT and to use the paper as a framework for expanding relevant discussion.
Terms
Co-register: Fusion of matching areas of abnormal isotope uptake on PET with the anatomic structures as depicted on CT
Links
CMS Transmittal 573, CR 3848, June 3, 2005
http://www.cms.hhs.gov/manuals/pm_trans/R573CP.pdf
Society of Nuclear Medicine, PET C&R Educational Materials, March 2005
http://interactive.snm.org/index.cfm?PageID=1110&RPID=3854&FileID=19826
CMS Transmittal 527, CR 3741, April 15, 2005
http://www.cms.hhs.gov/manuals/pm_trans/R527CP.pdf
Transmittal 518, CR 3741, April 1, 2005 - RESINCDED
http://www.cms.hhs.gov/manuals/pm_trans/R518CP.pdf
CMS Transmittal 31, CR 3741, April 1, 2005
http://www.cms.hhs.gov/manuals/pm_trans/R31NCD.pdf
CMS Transmittal 475, CR3726, February 11, 2005
http://www.cms.hhs.gov/manuals/pm_trans/R475CP.pdf
CMS Transmittal 402, CR 3621, December 17, 2004
http://www.cms.hhs.gov/manuals/pm_trans/R402CP.pdf
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3750.pdf
Federal Register Vol. 69, No. 216, November 15, 2004, p 66427
http://a257.g.akamaitech.net/7/257/2422/15nov20040800/edocket.access.gpo.gov/2004/pdf/04-24758.pdf