Content Section
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Medicare News Brief Medicare Information Resource
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MIR-2006-7B, July 2006
Billing PET Scans and Radioisotope Imaging Agents
PET scans can be billed to Medicare using the appropriate CPT code: 78459, 78491, 78492, 78608, 78609, or 78811-78816.
CPT codes 78491 and 78492 are myocardial blood flow studies and utilize rubidium 82 or N 13ammonia, while all the other studies utilize F 18DG.
Billing for myocardial blood flow scan requires that providers enter the CPT code 78491 or 78492 on the claim and also bill for the rubidium or N 13ammonia separately. Effective for dates of service on/after January 1, 2006, the rubidium may be billed using HCPCS code A9555. It may not be billed with A4641 for dates of service August 1, 2006 and after. The N 13ammonia may only be billed using HCPCS code A9526. The codes for the PET scan and the radioisotope are separately reimbursed. The rubidium and N 13ammonia are invoice-priced.
Currently, PET scans utilizing F 18DG are reimbursed differently, and claims should be coded differently. For these scans, the reimbursement for the radioisotope has been separately identified but then added to the reimbursement for the technical component of the PET scan. The radioisotope (A4641 or A9552) should not be billed separately.
For dates of service on or after August 1, 2006 , the cost of the radioisotope will be reimbursed separately for PET scans utilizing F 18DG and therefore, the fees for global and technical CPT codes 78459, 78608, 78609, and 78811-78816 will be revised. The revised fees can be found on the following Web sites:
New Jersey - http://www.empiremedicare.com/partbnj/billing/fees/fees2006.htm
New York - http://www.empiremedicare.com/partbny/billing/fees/fees2006.htm
Providers should bill the radioisotope separately using HCPCS code A9552, not A4641 when submitting claims for PET scans utilizing F 18DG. The F 18DG will be invoiced-priced.
As a reminder, invoice-priced services do not require an invoice be submitted. For paper claim submissions, the invoice cost of the radioisotope must be entered in Item 19 of the CMS-1500 form. For electronic claims submission, the invoice cost must be entered in either the 2300 (claim) or the 2400 (line) Loop in the NTE Segment. If your software is using the 2300 Loop, please make sure you place both the procedure code and the invoice cost in the NTE Segment.
For additional information on billing radioisotopes, refer to the following Web site:
http://www.empiremedicare.com/news/nynews05/120905dcr.htm
PET scan codes and the radioisotope (when appropriate) should be billed on the same claim. Claims submitted for either the PET scan alone or the radioisotope alone may be denied.
If you were incorrectly reimbursed for both the PET scan and the F 18DG radioisotope since 2005, you may be subject to recoupment of overpayment.
Code |
Mod |
Area |
Par Fee |
Non-Par Fee |
Lmt. Chrg. |
|
Area |
Par Fee |
Non-Par Fee |
Lmt. Chrg. |
78459 |
|
1 |
1,909.27 |
1,813.81 |
2,085.88 |
|
01 |
1,682.10 |
1,598.00 |
1,837.70 |
78459 |
TC |
1 |
1,792.10 |
1,702.50 |
1,957.88 |
|
01 |
1,573.51 |
1,494.83 |
1,719.05 |
78459 |
|
2 |
1,769.71 |
1,681.22 |
1,933.40 |
|
99 |
1,555.19 |
1,477.43 |
1,699.04 |
78459 |
TC |
2 |
1,656.40 |
1,573.58 |
1,809.62 |
|
99 |
1,450.87 |
1,378.33 |
1,585.08 |
78459 |
|
3 |
1,530.42 |
1,453.90 |
1,671.99 |
|
|
|
|
|
78459 |
TC |
3 |
1,427.35 |
1,355.98 |
1,559.38 |
|
|
|
|
|
78608 |
|
1 |
2,119.42 |
2,013.45 |
2,315.47 |
|
01 |
1,751.73 |
1,664.14 |
1,913.76 |
78608 |
TC |
1 |
2,029.07 |
1,927.62 |
2,216.76 |
|
01 |
1,666.05 |
1,582.75 |
1,820.16 |
78608 |
|
2 |
1,925.05 |
1,828.80 |
2,103.12 |
|
99 |
1,576.57 |
1,497.74 |
1,722.40 |
78608 |
TC |
2 |
1,836.27 |
1,744.46 |
2,006.13 |
|
99 |
1,493.91 |
1,419.21 |
1,632.09 |
78608 |
|
3 |
1,563.64 |
1,485.46 |
1,708.28 |
|
|
|
|
|
78608 |
TC |
3 |
1,482.64 |
1,408.51 |
1,619.79 |
|
|
|
|
|
78609 |
|
1 |
2,119.42 |
2,013.45 |
2,315.47 |
|
01 |
1,751.73 |
1,664.14 |
1,913.76 |
78609 |
TC |
1 |
2,029.07 |
1,927.62 |
2,216.76 |
|
01 |
1,666.05 |
1,582.75 |
1,820.16 |
78609 |
|
2 |
1,925.05 |
1,828.80 |
2,103.12 |
|
99 |
1,576.57 |
1,497.74 |
1,722.40 |
78609 |
TC |
2 |
1,836.27 |
1,744.46 |
2,006.13 |
|
99 |
1,493.91 |
1,419.21 |
1,632.09 |
78609 |
|
3 |
1,563.64 |
1,485.46 |
1,708.28 |
|
|
|
|
|
78609 |
TC |
3 |
1,482.64 |
1,408.51 |
1,619.79 |
|
|
|
|
|
78811 |
|
1 |
2,119.42 |
2,013.45 |
2,315.47 |
|
01 |
1,751.73 |
1,664.14 |
1,913.76 |
78811 |
TC |
1 |
2,023.58 |
1,922.40 |
2,210.76 |
|
01 |
1,661.68 |
1,578.60 |
1,815.39 |
78811 |
|
2 |
1,925.05 |
1,828.80 |
2,103.12 |
|
99 |
1,576.57 |
1,497.74 |
1,722.40 |
78811 |
TC |
2 |
1,830.32 |
1,738.80 |
1,999.62 |
|
99 |
1,489.66 |
1,415.18 |
1,627.46 |
78811 |
|
3 |
1,563.64 |
1,485.46 |
1,708.28 |
|
|
|
|
|
78811 |
TC |
3 |
1,478.08 |
1,404.18 |
1,614.81 |
|
|
|
|
|
78812 |
|
1 |
2,119.42 |
2,013.45 |
2,315.47 |
|
01 |
1,751.73 |
1,664.14 |
1,913.76 |
78812 |
TC |
1 |
2,001.11 |
1,901.05 |
2,186.21 |
|
01 |
1,640.10 |
1,558.10 |
1,791.82 |
78812 |
|
2 |
1,925.05 |
1,828.80 |
2,103.12 |
|
99 |
1,576.57 |
1,497.74 |
1,722.40 |
78812 |
TC |
2 |
1,808.41 |
1,717.99 |
1,975.69 |
|
99 |
1,468.85 |
1,395.41 |
1,604.72 |
78812 |
|
3 |
1,563.64 |
1,485.46 |
1,708.28 |
|
|
|
|
|
78812 |
TC |
3 |
1,457.82 |
1,384.93 |
1,592.67 |
|
|
|
|
|
78813 |
|
1 |
2,354.91 |
2,237.16 |
2,572.73 |
|
01 |
1,946.37 |
1,849.05 |
2,126.41 |
78813 |
TC |
1 |
2,232.24 |
2,120.63 |
2,438.72 |
|
01 |
1,830.56 |
1,739.03 |
1,999.88 |
78813 |
|
2 |
2,138.95 |
2,032.00 |
2,336.80 |
|
99 |
1,751.75 |
1,664.16 |
1,913.78 |
78813 |
TC |
2 |
2,018.06 |
1,917.16 |
2,204.73 |
|
99 |
1,640.01 |
1,558.01 |
1,791.71 |
78813 |
|
3 |
1,737.38 |
1,650.51 |
1,898.09 |
|
|
|
|
|
78813 |
TC |
3 |
1,627.65 |
1,546.27 |
1,778.21 |
|
|
|
|
|
78814 |
|
1 |
2,502.98 |
2,377.83 |
2,734.50 |
|
01 |
2,099.23 |
1,994.27 |
2,293.41 |
78814 |
TC |
1 |
2,368.62 |
2,250.19 |
2,587.72 |
|
01 |
1,972.20 |
1,873.59 |
2,154.63 |
78814 |
|
2 |
2,297.78 |
2,182.89 |
2,510.32 |
|
99 |
1,901.18 |
1,806.12 |
2,077.04 |
78814 |
TC |
2 |
2,165.50 |
2,057.23 |
2,365.81 |
|
99 |
1,778.63 |
1,689.70 |
1,943.16 |
78814 |
|
3 |
1,880.11 |
1,786.10 |
2,054.02 |
|
|
|
|
|
78814 |
TC |
3 |
1,759.85 |
1,671.86 |
1,922.64 |
|
|
|
|
|
78815 |
|
1 |
2,914.50 |
2,768.78 |
3,184.10 |
|
01 |
2,468.35 |
2,344.93 |
2,696.67 |
78815 |
TC |
1 |
2,766.31 |
2,627.99 |
3,022.19 |
|
01 |
2,328.04 |
2,211.64 |
2,543.39 |
78815 |
|
2 |
2,696.65 |
2,561.82 |
2,946.09 |
|
99 |
2,243.35 |
2,131.18 |
2,450.86 |
78815 |
TC |
2 |
2,550.89 |
2,423.35 |
2,786.85 |
|
99 |
2,108.00 |
2,002.60 |
2,302.99 |
78815 |
|
3 |
2,213.27 |
2,102.61 |
2,418.00 |
|
|
|
|
|
78815 |
TC |
3 |
2,080.54 |
1,976.51 |
2,272.99 |
|
|
|
|
|
78816 |
|
1 |
3,475.38 |
3,301.61 |
3,796.85 |
|
01 |
2,954.91 |
2,807.16 |
3,228.23 |
78816 |
TC |
1 |
3,323.73 |
3,157.54 |
3,631.17 |
|
01 |
2,811.28 |
2,670.72 |
3,071.33 |
78816 |
|
2 |
3,225.80 |
3,064.51 |
3,524.19 |
|
99 |
2,689.08 |
2,554.63 |
2,937.82 |
78816 |
TC |
2 |
3,076.67 |
2,922.84 |
3,361.27 |
|
99 |
2,550.53 |
2,423.00 |
2,786.45 |
78816 |
|
3 |
2,650.34 |
2,517.82 |
2,895.49 |
|
|
|
|
|
78816 |
TC |
3 |
2,514.50 |
2,388.78 |
2,747.10 |
|
|
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© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.
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