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Recently the Society of Nuclear Medicine updated their consensus opinion on coding for F-18 PET bone imaging. They emphasize that:
- Medicare does NOT cover F-18 PET bone imaging and Medicare instructs providers to use the appropriate HCPCS G code for non-covered services for Medicare patients. Therefore for F-18 PET bone imaging providers must use HCPCS code G0235 PET imaging, any site not otherwise specified.
Note: Medicare recently issued Transmittal 1301 clearly stating that the only PET radiopharmaceuticals covered are FDG, Rubidium Rb 82, and N 13 Ammonia. See previous eNews on the Transmittal for details:
nps.cardinal.com/NPS/content/nucpharm/pet/pet_serv-dev_enews.asp?C=1&I=305
- For private payers it is inappropriate to code for F-18 PET bone imaging with the conventional bone scan CPT codes 78306 Bone and/or joint imaging; whole body or 78320 Bone and/or joint imaging; tomographic (SPECT). The SNM recommends using CPT code 78399 Unlisted musculoskeletal procedure and HCPCS code A4641 Radiopharmaceutical, diagnostic, not otherwise classified to identify the F-18 fluoride administered.
F-18 Fluoride PET Bone Imaging
Revised: September 24, 2007
Question
We have been asked to perform whole-body PET bone scans for some of our oncology patients using F-18 fluoride. What codes should we use: 78306, 78320 or both with a modifier 59. Also, is A4641 the proper code to bill for the F-18 fluoride?
Answer
There are no specific CPT codes that accurately describe Positron Emission Tomography (PET) bone imaging using F-18 fluoride. For third-party payers, in the absence of a specific CPT code, the SNM recommends using the unlisted CPT code 78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine to describe PET bone imaging.
The commonly performed conventional bone scans, CPT 78306 Bone and/or joint imaging; whole-body or CPT 78320 Bone and/or joint imaging; tomographic (SPECT), performed with a Tc-99m phosphonate compound, are now well-entrenched in todays medical terminology and is understood by payers to indicate a specific examination performed with a gamma camera and would NOT be appropriate coding for a PET imaging study.
A bone scan performed using a PET radiopharmaceutical, however, is a specialized examination (likely performed for suspected infection or metastatic disease) that consumes a different level of resources (e.g., PET scanner) and likely would have different relative value and classification (RVU)/ambulatory payment classification (APC) as well as, Practice Expense (PE) value; therefore, the unlisted codes are currently the appropriate codes to use for third party payers. To report the radiopharmaceutical supply, submit A4641 Radiopharmaceutical, diagnostic, not otherwise classified to identify and bill the F-18 fluoride administered.
For Medicare patients, providers must use HCPCS Level II code G0235 PET imaging, any site, not otherwise specified. The Medicare National Coverage Determination policy for PET is considered an exclusionary policy. This means that any indication not listed in the policy is considered non-covered. Therefore, PET bone imaging is considered non-covered by Medicare, and providers are instructed by Medicare to use HCPCS Level II G codes for non-covered services for Medicare patients.
Disclaimer
The opinions referenced are those of the members of the SNM Coding and Reimbursement Committee and their consultants based on their coding experience. They are based on the commonly used codes in Nuclear Medicine, which are not all inclusive. Always check with your local insurance carriers as policies vary by region. The final decision for the coding of a procedure must be made by the physician considering regulations of insurance carriers and any local, state or federal laws that apply to the physicians practice. The SNM and its representatives disclaim any liability arising from the use of these opinions.
Link to SNM coding opinion:
interactive.snm.org/index.cfm?PageID=5025&RPID=1995
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Reimbursement information is provided by Cardinal Health as general coding and payment information. This information is not intended to replace or serve as substitute for your duty to verify that such information is proper for your particular circumstances. Any codes reported should accurately reflect the procedures performed and the patient's conditions. You may want to consult with local payers to confirm compliance with local policies, or otherwise review and confirm reimbursement policies with your own legal or other professional advisors.
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