Health Information Management

Q&A: Why are we getting edits for PET scans?

APCs Insider, August 15, 2014

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A: Certain radiopharmaceuticals can only be reported with specific PET scan procedures. While you don’t indicate what the HCPCS codes are for the procedure or the radiopharmaceutical, you can take some steps to identify the problem.
First, check the HCPCS codes attached to the chargemaster numbers to be sure they are correct for the study and the radiopharmaceutical being reported. If they are correct, check that the same HCPCS code attached to the chargemaster is what is being reported on the claim. Many systems have tables and processes built into them and sometimes when code changes occur, something gets missed. Be sure to check for alternate payer screens to be sure the codes are correct and processing appropriately.
Next, check the combination of the radiopharmaceutical and the procedure being reported. The NCCI manual (chapter 12) includes specific information related to PET scans and radiopharmaceutical pairings: 
Positron emission tomography (PET) imaging requires use of a radiopharmaceutical diagnostic imaging agent. HCPCS codes A9555 (Rubidium Rb-82...) and A9526 (Nitrogen N-13 Ammonia...) may only be reported with PET scan CPT® codes 78491 and 78492. HCPCS code A9552 (Fluorodeoxyglucose F-18, FDG...) may only be reported with PET scan CPT codes 78459, 78608, and 78811-78816.
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.

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