PET/CT CPT Codes CPT / HCPCS CODES 78608 PET/CT imaging brain, metabolic evaluation 78815 PET/CT skull base to mid thigh 78816 PET/CT whole body for: • 18F sodium fluoride bone scan • melanoma • cutaneous lymphoma MODIFIERS PI - Initial Treatment Strategy CPT Coding for Positron Emission Tomography (PET) Imaging for Oncologic Purposes and Neurologic Diseases This is a coding document to assist in billing for PET/CT imaging. Please refer to the entire coverage and claims processing documents on the CMS website. Medicare has established limited coverage for PET/CT imaging: If you need precertification assistance, please call:215-503-4900PS - Subsequent TreatmentJeffersonStrategyOutpatient Imaging
PET/CT WILL NOT BE COVERED FOR SURVEILLANCE under any circumstances. Melanoma, cervical, and breast cancers are covered for Initial Treatment Strategy with exceptions. Thyroid cancer is now covered for all types of cellular origin. The prior requirements of follicular thyroid cancer only, treated by thyroidectomy and radioiodine ablation, with serum thyroglobulin > 10ng/mL and negative whole body I-131 scan are no longer required.
PET/CT CMS Coverage Update
Initial Treatment Strategy 1 PET/CT per patient, per diagnosis Guide the management of anti-tumor treatment for tumors suspected of being cancerous biopsy proven OR based on other diagnostic testing
*Additional PET/CT approval based on medical necessity Guide the management of anti-tumor treatment strategy AFTER completion of Initial Treatment Therapy-as approved by local MACs The National Oncologic PET Registry (NOPR) is no longer in effect as of June 11, 2013, EXCEPT for 18F Sodium Fluoride bone scans (for prostate cancer). This means pre and post-PET data collection is no longer necessary. All solid tumors are now covered for Initial and Subsequent Treatment Strategy EXCEPT prostate for Initial Treatment Strategy.
Jefferson Outpatient Imaging
ULTRASOUNDCategoryVASCULAR
SubsequentStrategyTreatment 3 PET/CT scans per patient, per diagnosis
Limit Purpose
The local Medicare Administrative Contractors (MACs) and private carriers will approve additional PET/CT scans based on medical necessity. It is recommended that physicians document all information that will support their ordering requests and increase the likelihood of obtaining approvals e.g.: tissue biopsy that was unsuccessful or places the patient at risk; any complaints, symptoms, or changes of patient status that will reaffirm suspected disease.
FDG PET for Solid Tumors and Myeloma Tumor Type Initial Treatment Strategy (formerly “diagnosis” & “staging”) Subsequent Treatment Strategy (formerly “restaging” and “monitoring reponse to treatment”) Colorectal Cover Cover Esophagus Cover Cover Head and Neck (not thyroid or CNS) Cover Cover Lymphoma Cover Cover Non-small cell lung Cover Cover Ovary Cover Cover Brain Cover Cover Cervix Cover with exceptions * Cover Small cell lung Cover Cover Soft tissue sarcoma Cover Cover Pancreas Cover Cover Testes Cover Cover Prostate Non-cover Cover Thyroid Cover Cover Breast (male and female) Cover with exceptions * Cover Melanoma Cover with exceptions * Cover All other solid tumors Cover Cover Myeloma Cover Cover All other cancers not listed Cover Cover PET/CT Covered Indications * Cervical: • Nationally non-covered for initial diagnosis of cervical cancer related to initial anti-tumor treatment strategy. * Breast: • Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. • Nationally covered for initial staging of metastatic disease. * Melanoma: • Nationally non-covered for initialstaging of regional lymph nodes. • All other indicication for initial anti-tumor treatment strategy for melanoma are nationally covered. PET/CT WILL NOT BE COVERED FOR SURVEILLANCE under any circumstances. Jefferson Outpatient Imaging
To schedule a PET/CT appointment, call 215-503-4900 PET/CT PET/CT assists in the diagnosis, staging, and recurrence of cancer. It is one of the most advanced non-invasive exams available for oncology. PET/CT in Primary Care PET/CT for initial diagnosis is covered by insurance for many indications, including SPN (solitary pulmonary nodules) of 8 mm or larger. PET/CT for SPN & Lung Nodules When Patient has Symptoms: • Send patient for X-ray • If X-ray reveals a nodule of 8 mm or larger, order a PET/CT immediately • PET/CT is Medicare approved for SPN & lung cancer • If PET/CT is negative, patient stays within your practice, “watch & wait” with CT scans • If PET/CT is positive, patient is staged and ready for treatment which saves time Why PET/CT vs Biopsy • PET/CT is covered by insurance • Biopsies are invasive, carry the risk of pneumothorax, and some may fail to produce a definitively negative diagnosis1 “FDG PET differentiates benign vs malignant SPNs with a high degree of accuracy. The judicious use of PET in the work-up of patients with SPNs is highly likely to prevent unnecessary biopsies and surgical procedures.”1 1 Lowe, Val et al: Prospective Investigation of Positron Emission Tomography in Lung Nodules. J Clin Oncology The Power of PET/CT ADVANCED » ACCURATE » NON-INVASIVE Jefferson Outpatient Imaging
To schedule a cardiac PET/CT at Jefferson Outpatient Imaging, please call or email Irene Orzechowski: 215-503-4923 | irene.orzechowski@jefferson.edu 850 Walnut Street ∞ Ground Floor ∞ Philadelphia, PA ∞ FREE PARKING ∞ 215-503-4900 ∞ JeffersonHealth.org/JOI Cardiac PET/CT Myocardial perfusion PET/CT is now available at Jefferson Outpatient Imaging in Center City. Cardiac PET/CT is used for the diagnosis and management of known or suspected coronary artery disease, including: • To screen for cardiovascular disease among symptomatic patients or those who have associated risk factors, e.g. family history or high cholesterol • To monitor the condition of the heart and the success of treatment in those who have been diagnosed with CAD • To evaluate previously detected blockages and determine candidacy for coronary stents or bypass surgery • To determine the extent of tissue damage and scarring following a heart attack and identify the appropriate treatment method Cardiac PET/CT is also recommended for patients who have had an inconclusive SPECT study, as well as patients with body characteristics and conditions that risk an inconclusive cardiac SPECT: • Obesity (BMI >30) • Diaphragmatic attenuation • Large breasts • Previous mastectomy • Breast implants • Chest wall deformity • Patients with body positioning challenges/limited mobility • Bowel loop • Pleural or pericardial effusion • Body size • Scar tissue • High-risk patients such as those with diabetes or chronic kidney JeffersondiseaseOutpatient Imaging
