Saturday, October 2, 2010

PET scan Procedure CODE 78815 78491, 78811 - 78816

Appropriate Procedure Codes Effective for PET Scans for Services Performed on or After January 28, 2005

All PET scan services require the use of a radiopharmaceutical diagnostic imaging agent (tracer). The applicable tracer code should be billed when billing for a PET scan service. See section 60.3.2 below for applicable tracer codes

Procedure Code Description

78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation

78491 Myocardial imaging, positron emission tomography (PET), perfusion, single study at rest or stress

78492 Myocardial imaging, positron emission tomography (PET), perfusion, multiple studies at rest and/or stress

78608 Brain imaging, positron emission tomography (PET); metabolic evaluation

78811 Tumor imaging, positron emission tomography (PET); limited area (eg, chest, head/neck)

78812 Tumor imaging, positron emission tomography (PET); skull base to mid-thigh

78813 Tumor imaging, positron emission tomography (PET); whole body

78814 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (e.g., chest, head/neck)

78815 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization;

78816 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body


Billing and Coding Guidelines



Billing should be submitted using the appropriate billing form and Procedure code for (1) tumor PET imaging (78811, 78812, or 78813), (2) tumor PET/CT imaging (78814, 78815, or 78816), or (3) for brain imaging (78608) when a dedicated brain PET study was done for brain tumor evaluation. The QR modifier is appended to the Procedure code and, for Fiscal Intermediaries (hospital billing), providers must also add the V70.7 diagnosis code in the second diagnosis position on the UB claim form.


NOPR Question: Can I code and bill for two oncology PET procedures on the same date of service (SDOS)? 


SNM comment:

The answer is both no and yes. Procedure guidance is clear in the Procedure parenthetical following the PET tumor codes: "report 78811-78816 only once per imaging session". Therefore, providers may use one Procedure code in the series 78811-78816 when billing PET tumor imaging.

" NO " : - As an example, it would not be appropriate to code and bill for both a limited bone scan (Procedure 78300) and a whole body study (Procedure 78306). The limited study is considered part of the whole body study. In general, when the AMA RUC (RUC stands for Relative Update Committee) values Procedure codes, it does so on the basis of a typical study (including additional views). Providers should choose the appropriate code to reflect the body area imaged. Even if the brain is included in an extended "skull base to mid thigh" study, the code for brain imaging should not be used in addition to Procedure 78812 or 78815.

"YES" - If a separate brain PET is indicated and requested in addition to a PET or PET/CT body study (Procedure 78811-78816) then it may be appropriate to submit two Procedure codes. An example would be a patient with breast cancer that is metastatic to the brain with a residual enhancing lesion on MRI after stereotactic radiosurgery, and a dedicated brain PET procedure is requested for evaluation of "viable tumor versus radiation necrosis", and a PET/CT of the skull base to mid thigh is requested for restaging to assess for evidence of progression at other sites. This would be coded as Procedure 78608 with modifier-59 for the brain study and 78815 for the torso study. (If this is a Medicare patient and the site participates in NOPR, then add the QR modifier to the brain study, because brain tumor studies are only covered nationally under NOPR . If this is a Medicare patient and your imaging facility does NOT participate in NOPR, use code G0235 (PET imaging, any site, not otherwise specified ) for Medicare non-covered PET services. If this is a third party other than Medicare check with the payer, for the correct coding could be either Procedure 78608- 59 or the G0235 code.)


Effective for dates of service on or after June 11, 2013, MACs will use the following messages when denying claims in excess of three for PET FDG scans for subsequent treatment strategy when the –KX modifier is not included, identified by Procedure codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier –PS, HCPCS A9552, and the same cancer diagnosis code:

• Claim Adjustment Reason Code (CARC) 96: “Non-Covered Charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”

• Remittance Advice Remarks Code (RARC) N435: “Exceeds number/frequency approved/allowed within time period without support documentation.”

• Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.

• Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.


Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes

Effective for claims with dates of service on or after February 26, 2010, contractors shall return as unprocessable NaF-18 PET oncologic claims billed with modifier TC or globally (for A/B MACs (A) modifier TC or globally does not apply) and HCPCS A9580 to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis that do not include ALL of the following:

• PI or PS modifier AND

• PET or PET/CT Procedure code (78811, 78812, 78813, 78814, 78815, 78816) AND

• Cancer diagnosis code AND

• Q0 modifier - Investigational clinical service provided in a clinical research study, are present on the claim.

NOTE: For institutional claims, continue to include ICD-9 diagnosis code V70.7 or ICD-10 diagnosis code Z00.6 and condition code 30 to denote a clinical study.

 Billing for A/B MACs

PET claims billed to inform initial treatment strategy with the following Procedure codes AND modifier –PI: 78608, 78811, 78812, 78813, 78814, 78815, 78816.

Effective for claims with dates of service on or after April 3, 2009, contractors shall accept FDG PET claims with modifier –PS for the subsequent treatment strategy for solid tumors using a Procedure code above AND a cancer diagnosis code.

Contractors shall also accept FDG PET claims billed to inform initial treatment strategy or subsequent treatment strategy when performed under CED with one of the PET or PET/CT Procedure codes above AND modifier -PI OR modifier -PS AND a cancer diagnosis code AND modifier -Q0/Q1. Effective for services performed on or after June 11, 2013, the CED requirement has ended and modifier -Q0/-Q1, along with condition code 30 (institutional claims only), or V70.7 (both institutional and practitioner claims) are no longer required


Effective for dates of service on or after June 11, 2013, contractors shall use the following messages when denying claims in excess of three for PET FDG scans for subsequent treatment strategy when the –KX modifier is not included, identified by Procedure codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier –PS, HCPCS A9552, and the same cancer diagnosis code.

CARC 96: “Non-Covered Charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”

RARC N435: “Exceeds number/frequency approved/allowed within time period without support documentation.”

MSN 23.17: “Medicare won’t cover these services because they are not considered medically necessary.” Spanish Version: “Medicare no cubrirá estos servicios porque no son considerados necesarios por razones médicas.”

Contractors shall use Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.


COVERAGE Guideline from BCBS:

Laser-assisted tympanostomy (includes PET insertion) is considered medically necessary in patients with chronic otitis who meet criteria for conventional insertion of a PET.

Laser-assisted myringotomy (does not include PET insertion) is considered not medically necessary as a treatment of acute otitis media.

Laser-assisted myringotomy is considered experimental or investigational as an alternative to tympanostomy.

NOTE:

Myringotomy and tympanostomy are terms used interchangeably to describe an opening in the tympanic membrane.

In this policy, myringotomy will be used to describe a temporary opening in the tympanic membrane without insertion of a PET, and tympanostomy will be used to describe an opening in the tympanic membrane in conjunction with insertion of a PET.

This categorization is consistent with the CPT coding of these two procedures.

DESCRIPTION:

Insertion of a PET is indicated for continuous middle ear aeration in patients with chronic otitis media with effusion (OME). It is estimated that some 27 million cases of otitis media occur each year and that 1,000,000 children undergo PET insertion each year, making this procedure the most frequently performed pediatric surgery requiring anesthesia. Nevertheless, since conventional PET requires general anesthesia, it is typically not considered unless multiple courses of antibiotics fail to clear the infection and resolve the effusion. Myringotomy alone is less frequently performed. Since a conventional incision typically closes up within 1 or 2 days it cannot be used for prolonged ventilation of the middle ear. Myringotomies can be used to acutely decompress the ear and thus relieve pain. In addition, aspiration of fluid can be used for diagnostic purposes to determine whether the fluid is sterile and, if not, to assess antibiotic sensitivities.

Recently, laser-assisted procedures have become available, not only to perform myringotomies, but also to perform tympanostomies with PET insertion. Laser-assisted procedures can be performed in the pediatrician’s office using only local anesthesia. For example, the tympanic membrane may be anesthetized using topical tetracaine. A video monitor is used to pinpoint the exact location for the hole, and the precise size of the hole is programmed into the computer. A CO-2 flashscanner laser requires one tenth of a second to create a bloodless opening in the tympanic membrane. A PET tube may be inserted, if desired, under microscopic control. OtoLam® is a laser device approved by the U.S. Food and Drug Administration (FDA) that is intended to be used as a technique for performing myringotomies and tympanostomies.

As a surgical tool, the laser-assisted approach is an alternative to conventional myringotomy and tympanostomy. However, the opening created by a laser-assisted myringotomy may remain patent for a longer period of time (3–4 weeks) compared to conventional myringotomies (several days). Thus a laser-assisted myringotomy could be potentially considered an alternative to a conventional tympanostomy with PET insertion, a unique indication.

RATIONALE:

Chronic Otitis Media

A literature review identified two articles focusing on laser-assisted procedures in patients with chronic otitis media. Brodsky and colleagues reported on a case series of 54 patients (96 ears), aged 6 months to 23 years, who met criteria for insertion of a pressure equalizing tube (PET). These criteria included recurrent otitis media, chronic otitis media with effusion, or eustachian tube dysfunction. All patients had failed medical management. All procedures were performed in the office with the use of topical anesthesia. Pain was described as “absent” in 39%, “tolerable” in 30%, and “severe” in 30% immediately after the procedure. Within 5 minutes the pain was reported “absent” in 75%, “tolerable” in 22%, and“severe” in 5%. Ninety-two percent of parents were highly satisfied with the procedure as an alternative to PET insertion using general anesthesia. The average time of the procedure was 8.57 minutes. The authors concluded that office-based laser-assisted tympanostomy with PET insertion is possible in a broad range of patients. The advantage of the laser-assisted approach is the fact that it can be performed without the need for general anesthesia.

Silverstein and colleagues reported on a case series of 30 patients (39 ears) with persistent serous otitis media who underwent a laser- assisted myringotomy without insertion of a pressure equalizing tube. Thus the laser-assisted approach was an alternative to PET insertion, a unique indication. The otitis media was cured in 31 ears after the first treatment and in 1 patient after two treatments for an overall success rate of 75%. Four patients (5 ears) eventually required PET insertion. The patency time (i.e., time for the myringotomy to heal) averaged 3.17 weeks. All but 2 myringotomies healed without scarring.

As addressed in the discussion section, a laser-assisted myringotomy is a unique procedure when it is considered an alternative to a conventional tympanostomy with tube insertion. The minimal time of aeration leading to resolution of chronic otitis media, while also reducing the risk of recurrent disease, is not precisely known. In the above study, laser-assisted myringotomies remained patent for an average of 3.17 weeks. In contrast, short-term PETs typically remain functional for 6–12 months, depending on the type of tube. The length of follow-up in the above study was not provided, so it cannot be determined how the long-term outcomes associated with laser-assisted myringotomy compare to conventional PET insertion. Silverstein and colleagues recommend that patients who fail short-term aeration with a laser-assisted myringotomy undergo a subsequent tympanostomy with PET insertion, although this treatment hierarchy was not a specific focus of the study.

Acute Otitis Media

Surgical aeration of the middle ear is indicated to acutely relieve pressure and to restore hearing. Symptoms suggestive of acute otitis media are ear pain, irritability, sleepiness in conjunction with bulging immobility of the tympanic membrane, erythema, loss of landmarks, and TM exudate. Conventional treatment of acute otitis media includes antibiotics. Problematic patients are those who continue to be symptomatic despite antibiotic therapy. Many times these patients may receive several courses of empirically chosen antibiotics. Laser-assisted myringotomy has been proposed as a technique to simultaneously provide an accurate diagnosis with the culture results used to select an appropriate antibiotic. However, this unique role of myringotomy has not been the subject of a peer- reviewed article and it is not known whether the use of the laser procedure provides any advantage compared to the conventional office- based procedure using a myringotomy knife.


PRICING:

There are no specific CPT codes for laser-assisted tympanostomy and myringotomy.

NOTE:

There will be no additional reimbursement for any of these procedures performed as “laser assisted”.

Covered ICD 10 CODE

Code Description

A18.84 Tuberculosis of heart
I06.0 Rheumatic aortic stenosis
I06.1 Rheumatic aortic insufficiency
I06.2 Rheumatic aortic stenosis with insufficiency
I06.8 Other rheumatic aortic valve diseases
I06.9 Rheumatic aortic valve disease, unspecified
I08.0 Rheumatic disorders of both mitral and aortic valves
I08.8 Other rheumatic multiple valve diseases
I08.9 Rheumatic multiple valve disease, unspecified
I20.0 Unstable angina
I20.1 Angina pectoris with documented spasm
I20.8 Other forms of angina pectoris
I20.9 Angina pectoris, unspecified
I21.01
ST elevation (STEMI) myocardial infarction involving left main
coronary artery
I21.02
ST elevation (STEMI) myocardial infarction involving left anterior
descending coronary artery
I21.09
ST elevation (STEMI) myocardial infarction involving other coronary
artery of anterior wall
I21.11
ST elevation (STEMI) myocardial infarction involving right coronary
artery
I21.19
ST elevation (STEMI) myocardial infarction involving other coronary
artery of inferior wall
I21.21
ST elevation (STEMI) myocardial infarction involving left circumflex
coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I22.0
Subsequent ST elevation (STEMI) myocardial infarction of anterior
wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9
Subsequent ST elevation (STEMI) myocardial infarction of unspecified
site
I23.0
Hemopericardium as current complication following acute myocardial
infarction
I23.1
Atrial septal defect as current complication following acute
myocardial infarction
I23.2
Ventricular septal defect as current complication following acute
myocardial infarction
Code Description
I23.3
Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
I23.6
Thrombosis of atrium, auricular appendage, and ventricle as current
complications following acute myocardial infarction
I23.7 Postinfarction angina
I23.8 Other current complications following acute myocardial infarction
I24.0 Acute coronary thrombosis not resulting in myocardial infarction
I24.1 Dressler's syndrome
I24.8 Other forms of acute ischemic heart disease
I24.9 Acute ischemic heart disease, unspecified
I25.10
Atherosclerotic heart disease of native coronary artery without
angina pectoris
I25.110
Atherosclerotic heart disease of native coronary artery with unstable
angina pectoris
I25.111
Atherosclerotic heart disease of native coronary artery with angina
pectoris with documented spasm
I25.118
Atherosclerotic heart disease of native coronary artery with other
forms of angina pectoris
I25.119
Atherosclerotic heart disease of native coronary artery with
unspecified angina pectoris
I25.2 Old myocardial infarction
I25.3 Aneurysm of heart
I25.41 Coronary artery aneurysm
I25.42 Coronary artery dissection
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.700
Atherosclerosis of coronary artery bypass graft(s), unspecified, with
unstable angina pectoris
I25.701
Atherosclerosis of coronary artery bypass graft(s), unspecified, with
angina pectoris with documented spasm
I25.708
Atherosclerosis of coronary artery bypass graft(s), unspecified, with
other forms of angina pectoris
I25.709
Atherosclerosis of coronary artery bypass graft(s), unspecified, with
unspecified angina pectoris
I25.710
Atherosclerosis of autologous vein coronary artery bypass graft(s)
with unstable angina pectoris
I25.711
Atherosclerosis of autologous vein coronary artery bypass graft(s)
with angina pectoris with documented spasm
I25.718
Atherosclerosis of autologous vein coronary artery bypass graft(s)
with other forms of angina pectoris
I25.719
Atherosclerosis of autologous vein coronary artery bypass graft(s)
with unspecified angina pectoris
I25.720
Atherosclerosis of autologous artery coronary artery bypass graft(s)
with unstable angina pectoris
Code Description
I25.721
Atherosclerosis of autologous artery coronary artery bypass graft(s)
with angina pectoris with documented spasm
I25.728
Atherosclerosis of autologous artery coronary artery bypass graft(s)
with other forms of angina pectoris
I25.729
Atherosclerosis of autologous artery coronary artery bypass graft(s)
with unspecified angina pectoris
I25.730
Atherosclerosis of nonautologous biological coronary artery bypass
graft(s) with unstable angina pectoris
I25.731
Atherosclerosis of nonautologous biological coronary artery bypass
graft(s) with angina pectoris with documented spasm
I25.738
Atherosclerosis of nonautologous biological coronary artery bypass
graft(s) with other forms of angina pectoris
I25.739
Atherosclerosis of nonautologous biological coronary artery bypass
graft(s) with unspecified angina pectoris
I25.750
Atherosclerosis of native coronary artery of transplanted heart with
unstable angina
I25.751
Atherosclerosis of native coronary artery of transplanted heart with
angina pectoris with documented spasm
I25.758
Atherosclerosis of native coronary artery of transplanted heart with
other forms of angina pectoris
I25.759
Atherosclerosis of native coronary artery of transplanted heart with
unspecified angina pectoris
I25.760
Atherosclerosis of bypass graft of coronary artery of transplanted
heart with unstable angina
I25.761
Atherosclerosis of bypass graft of coronary artery of transplanted
heart with angina pectoris with documented spasm
I25.768
Atherosclerosis of bypass graft of coronary artery of transplanted
heart with other forms of angina pectoris
I25.769
Atherosclerosis of bypass graft of coronary artery of transplanted
heart with unspecified angina pectoris
I25.790
Atherosclerosis of other coronary artery bypass graft(s) with unstable
angina pectoris
I25.791
Atherosclerosis of other coronary artery bypass graft(s) with angina
pectoris with documented spasm
I25.798
Atherosclerosis of other coronary artery bypass graft(s) with other
forms of angina pectoris
I25.799
Atherosclerosis of other coronary artery bypass graft(s) with
unspecified angina pectoris
I25.810
Atherosclerosis of coronary artery bypass graft(s) without angina
pectoris
I25.811
Atherosclerosis of native coronary artery of transplanted heart
without angina pectoris
I25.812
Atherosclerosis of bypass graft of coronary artery of transplanted
heart without angina pectoris
I25.82 Chronic total occlusion of coronary artery
Code Description
I25.83 Coronary atherosclerosis due to lipid rich plaque
I25.84 Coronary atherosclerosis due to calcified coronary lesion
I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
I35.0 Nonrheumatic aortic (valve) stenosis
I35.1 Nonrheumatic aortic (valve) insufficiency
I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency
I35.8 Other nonrheumatic aortic valve disorders
I35.9 Nonrheumatic aortic valve disorder, unspecified
I42.0 Dilated cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
I42.2 Other hypertrophic cardiomyopathy
I42.5 Other restrictive cardiomyopathy
I42.6 Alcoholic cardiomyopathy
I42.7 Cardiomyopathy due to drug and external agent
I42.8 Other cardiomyopathies
I42.9 Cardiomyopathy, unspecified
I43 Cardiomyopathy in diseases classified elsewhere
I44.0 Atrioventricular block, first degree
I44.1 Atrioventricular block, second degree
I44.2 Atrioventricular block, complete
I44.30 Unspecified atrioventricular block
I44.4 Left anterior fascicular block
I44.5 Left posterior fascicular block
I44.60 Unspecified fascicular block
I44.69 Other fascicular block
I44.7 Left bundle-branch block, unspecified
I45.2 Bifascicular block
I45.6 Pre-excitation syndrome
I47.0 Re-entry ventricular arrhythmia
I47.1 Supraventricular tachycardia
I47.2 Ventricular tachycardia
I47.9 Paroxysmal tachycardia, unspecified
I48.0 Paroxysmal atrial fibrillation
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillation
I48.3 Typical atrial flutter
I48.4 Atypical atrial flutter
I48.91 Unspecified atrial fibrillation
I48.92 Unspecified atrial flutter
I49.2 Junctional premature depolarization
I49.9 Cardiac arrhythmia, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
Code Description
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40
Unspecified combined systolic (congestive) and diastolic (congestive)
heart failure
I50.41
Acute combined systolic (congestive) and diastolic (congestive) heart
failure
I50.42
Chronic combined systolic (congestive) and diastolic (congestive)
heart failure
I50.43
Acute on chronic combined systolic (congestive) and diastolic
(congestive) heart failure
I50.9 Heart failure, unspecified
I51.0 Cardiac septal defect, acquired
I51.3 Intracardiac thrombosis, not elsewhere classified
I51.81 Takotsubo syndrome
I97.0 Postcardiotomy syndrome
I97.110 Postprocedural cardiac insufficiency following cardiac surgery
I97.111 Postprocedural cardiac insufficiency following other surgery
I97.120 Postprocedural cardiac arrest following cardiac surgery
I97.121 Postprocedural cardiac arrest following other surgery
I97.130 Postprocedural heart failure following cardiac surgery
I97.131 Postprocedural heart failure following other surgery
I97.190
Other postprocedural cardiac functional disturbances following
cardiac surgery
I97.191
Other postprocedural cardiac functional disturbances following other
surgery
Q23.1 Congenital insufficiency of aortic valve
Q24.5 Malformation of coronary vessels
Q25.2 Atresia of aorta
Q25.3 Supravalvular aortic stenosis
R06.02 Shortness of breath
R07.1 Chest pain on breathing
R07.2 Precordial pain
R07.81 Pleurodynia
R07.82 Intercostal pain
R07.89 Other chest pain
R07.9 Chest pain, unspecified
R55 Syncope and collapse
R57.0 Cardiogenic shock
R68.89 Other general symptoms and signs
R94.30 Abnormal result of cardiovascular function study, unspecified
R94.31 Abnormal electrocardiogram [ECG] [EKG]
R94.39 Abnormal result of other cardiovascular function study
Z01.810 Encounter for preprocedural cardiovascular examination
Code Description
Z03.89
Encounter for observation for other suspected diseases and
conditions ruled out
Z48.21 Encounter for aftercare following heart transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z82.41 Family history of sudden cardiac death
Z82.49
Family history of ischemic heart disease and other diseases of the
circulatory system
Z94.1 Heart transplant status
Z94.3 Heart and lungs transplant status
Z95.1 Presence of aortocoronary bypass graft
Z95.3 Presence of xenogenic heart valve
Z95.4 Presence of other heart-valve replacement
Z95.5 Presence of coronary angioplasty implant and graft
Z98.61 Coronary angioplasty status
Z98.89 Other specified postprocedural states

1 comment:

  1. When billing for Medicare the radiology reading uses what modifier?

    ReplyDelete

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