Pet Scan CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

Pet Scan CPT code(s) 78811-78816 bills for the services when the physician performs a Positron emission tomography (PET) scan of different body areas or anatomical regions with or without a CT scan.

Pet Scan CPT Code Description

The PET produces thin slice images of the body. These images reassemble into 3D representations by detecting positron-emitting radionuclides from radio agents introduced into the body. 

Computed tomography (CT) directs multiple narrow beams of x-rays around a body structure to produce thin, cross-sectional views of the body’s anatomical layers (or slices). The PET scan is highly sensitive to the metabolic activity of the tumor, while CT provides a detailed internal picture of the size, shape, and location of cancer. 

PET alone has a definite limitation concerning spatial resolution and physiological uptake of the radiopharmaceutical tracer. It can be underestimated or misinterpreted in some areas without accurate anatomical correlations. 

Scanners that concurrently utilize PET with CT imaging correct this limitation of PET by fusing the data for the precise anatomical location together with highly sensitive metabolic imaging. Report 78814 for concurrently acquired PET/CT imaging of a limited area, such as the head and neck alone; 78815 for imaging from the skull base to the mid-thigh; and 78816 for whole-body scanning.

CPT 78811

CPT 78811 bills for service when the physician performs PET scan imaging; limited areas such as chest, head, or neck.

CPT 78812

CPT 78812 bills for service when the physician performs PET imaging from skull base to mid-thigh.

CPT 78813

CPT 78813 bills for service when the physician performs PET scan imaging of the whole body.

CPT 78814

CPT 78814 bills for service when the physician performs a PET scan with parallel acquired CT for attenuation-correction and anatomical localization imaging; limited areas such as the chest, head, or neck

CPT 78815

CPT 78815 bills for service when the physician performs a PET scan with parallel acquired for attenuation correction and anatomical localization imaging from skull base to mid-thigh

CPT 78816

CPT 78816 bills for service when the physician performs PET with parallel acquired computed tomography (CT) for attenuation correction and anatomical localization imaging of the whole body

Pet Scan CPT Code Reimbursement 

A maximum of one unit can be a bill on the same service date of Pet Scan CPT code(s) 78811-78816. In contrast, the two units allow when documentation supports the medical necessity of the service.  

The cost and RUVS of CPT 78811 with modifier 26 are $77.20 and 2.23091 when performed in the facility. In contrast, the reimbursement and RUVS of 78811 with modifier 26 are $77.20 and 2.23091 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78811 with modifier 26 are $77.20 and 2.23091. 

The cost and RUVS of CPT 78811 with modifier TC are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 78811 with modifier TC are $0.00 and 0.00000 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78811 with modifier TC are $1568.20 and 45.31557.

In OPPS global, the cost and RUVS of Pet Scan CPT code 78811 with the global modifier are $1589.55 and 45.93256. The cost and RUVS of CPT 78811 with global billing are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of 78811 with global billing are $0.00 and 0.00000 when performed in the non-facility.

The cost and RUVS of CPT 78812 with modifier 26 are $97.71 and 2.82345 when performed in the facility. In contrast, the reimbursement and RUVS of 78812 with modifier 26 are $97.71 and 2.82345 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78812 with modifier 26 are $97.71 and 2.82345.  

The cost and RUVS of Pet Scan CPT code 78812 with modifier TC are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 78812 with modifier TC are $0.00 and 0.00000 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78812 with modifier TC are $1775.98 and 51.31982.  

In OPPS global, the cost and RUVS of CPT 78812 with a global modifier are $1803.70 and 52.12063. The cost and RUVS of CPT 78812 with global billing are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of 78812 with global billing are $0.00 and 0.00000 when performed in the non-facility.

The cost and RUVS of CPT 78813 with modifier 26 are $97.95 and 2.83049 when performed in the facility. In contrast, the reimbursement and RUVS of 78813 with modifier 26 are $$97.95 and 2.83049 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78813 with modifier 26 are $97.95 and 51.31982. 

The cost and RUVS of Pet Scan CPT code 78813 with modifier TC are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 78813 with modifier TC are $0.00 and 0.00000 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78813 with modifier TC are $1775.98 and 2.79571.  

In OPPS global, the cost and RUVS of CPT 78813 with the global modifier are $1801.40 and 52.05431. The cost and RUVS of CPT 78813 with global billing are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of 78813 with global billing are $0.00 and 0.00000 when performed in the non-facility.

. In OPPS global, the cost and RUVS of CPT 78814 with modifier 26 are 111.42 and 3.21973. The cost and RUVS of CPT 78814 with modifier 26 are $111.42 and 3.21973 when performed in the facility. In contrast, the reimbursement and RUVS of 78814 with modifier 26 are 111.42 and 3.21973 when performed in the non-facility 

The cost and RUVS of CPT 78814 with modifier TC are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 78814 with modifier TC are $0.00 and 0.00000 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78814 with modifier TC are $1775.98 and 51.31982.  

In OPPS global, the cost and RUVS of CPT 78814 with a global modifier are $1807.62 and 52.23395. The cost and RUVS of CPT 78814 with global billing are $0.00 and 0.00000  when performed in the facility. In contrast, the reimbursement and RUVS of 78814 with global billing are $0.00 and 0.00000 when performed in the non-facility.

The cost and RUVS of CPT 78815 with modifier 26 are $123.64 and 3.57282 when performed in the facility. In contrast, the reimbursement and RUVS of 78815 with modifier 26 are $123.64 and 3.57282 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78815 with modifier 26 are $123.64 and 3.57282.  

The cost and RUVS of Pet Scan CPT code 78815 with modifier TC are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 78815 with modifier TC are $0.00 and 0.00000 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78815 with modifier TC are $1775.98 and 51.31982.  

In OPPS global, the cost and RUVS of CPT 78815 with a global modifier are $1811.13 and 52.33552. The price and RUVS of CPT 78815 with global billing are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of 78815 with global billing are $0.00 and 0.00000 when performed in the non-facility.

The cost and RUVS of CPT 78816 with modifier 26 are $124.74 and 3.60463 when performed in the facility. In contrast, the reimbursement and RUVS of 78816 with modifier 26 are $124.74 and 3.60463 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78816 with modifier 26 are $124.74 and 3.60463.   

The cost and RUVS of CPT 78816 with modifier TC are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 78816 with modifier TC are $0.00 and 0.00000 when performed in the non-facility. In OPPS global, the cost and RUVS of CPT 78816 with modifier TC are  $1775.98 and 51.31982.   

In OPPS global, the cost and RUVS of Pet Scan CPT code 78816 with global modifier are $1810.06 and 52.30445. The price and RUVS of CPT 78816 with global billing are $0.00 and 0.00000 when performed in the facility. In contrast, the reimbursement and RUVS of 78816 with global billing are $0.00 and 0.00000 when performed in the non-facility.

Pet Scan CPT Code Billing Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate. 

The payable dx codes range from category D00-C85. CT scan performed for other than attenuation correction and anatomical localization (report with appropriate site-specific CT code and modifier 59).

If Ocular radio phosphorus tumor identification (78800) performs, It is appropriate to report separately with CPT 78800 instead of CPT code 78811-78815.

If a PET brain scan (78608-78609) performs, It is appropriate to report separately with CPT 78608-78609 instead of CPT code 78811-78815.

If PET myocardial imaging (78459, 78491-78492) performs, It is appropriate to report separately with CPT 78459, 78491-78492 instead of CPT code 78811-78815.

It is appropriate to report radiopharmaceutical(s) and or drug(s) supplied with Appropriate HCPCS level II codes in combination with CPT 78811-78815

Pet Scan CPT Code Modifiers 

The following are the list modifiers when Pet Scan CPT code(s) 78811-78816 bills:  

22, 23, 26, 52, 58, 59, 76, 77, 78, 79, 99, AI, AQ, AR, CC, CR, ET, EY, FX, FY, GA, GC, GK, GR, GU, GY, GZ, KX, PT, Q5, Q6, QJ, SG, TC, XR, XP, XU, XS. TC, PI, PS

The most frequent bill modifiers are 26, TC, 77, 76, 59, or X {E, P, S, U} with 78811-78816.    

Modifier 26 bills to indicate the professional component of services when attached with 78811-78816. It shows that the Physician work as an employee in a hospital and facility, not owning the equipment.  

Modifier TC applicable with 78811-78816 indicates the Technical component or machinery used in service. It usually bills with Hospital and facility claims.  

CPT 78811-78816 bills globally when physician-owned the office and equipment. Service bills without TC and 26 modifiers. 

Modifier 76 is applicable with Pet Scan CPT code(s) 78811-78816 when a similar service performs by the Same Physician on the same day.  

Modifier 77 is applicable with CPT 78811-78816 when a similar service performs by a different Physician on the same service date. 

Modifier 59 is applicable with CPT 78811-78816 when a Distinct service performs by the physician and bundled with another procedure on the same date.   

Modifier X {E, P, S, U} is applicable instead of Modifier 59 with Pet Scan CPT code(s) 78811-78816 when service bills to medicare insurance. It divides the modifier into four parts for further specification of the procedure. 

If physicians believe that Medicare will deny such service, reporting with a GA  modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and  78811-78816 must apply the GA modifier to that service. 

Modifier 52 is applicable when the physician cannot complete the procedure due to unavoidable circumstances.

Pet Scan CPT Code Examples

The following is the example when Pet Scan CPT code(s) 78811-78816 bills:

PET-CT SCAN: CPT 78816

HISTORY: History of right lower extremity sarcoma.

PROCEDURE: Following the IV injection of 18-fluoro-2- deoxyglucose (FDG) and a standard uptake of approximately 60 minutes, a non-contrast CT scan is followed by a PET CT  scan of the whole body comprised, from the top of the head to the feet. 

CT attenuation-corrected axial, sagittal, coronal, and rotational MIP images acquire. The non-contrast low-dose CT scan was used for anatomic localization and photon attenuation correction of the PET scan and is not for standard alone diagnosis.

Blood glucose level (mg/the L): 140

FDG dose (mCi): 11.6

Correlative studies: There are no prior studies. Prior imaging has consisted of a CT urogram from 1/5/2021 and MRI studies of the right lower extremity.

FINDINGS:

Head/Neck:  There is no abnormal uptake in the head or neck.

Chest: There is no abnormal uptake within the lungs or mediastinum.

Abdomen/Pelvis: Normal liver background activity demonstrated with SUV between 3.3 and 4.3. There are no areas of increased suspicious activity within the liver. There is no abnormal uptake within the abdominal mesentery or retroperitoneum. There is increased uptake with an SUV max of 6.4 in the high left inguinal region corresponding to two small nodular densities.

Skeletal: There are two foci of increased uptake laterally along the right tensor fascia lata with an SUV max of 4.9, which is deep to an area of linear density extending from the skin surface, which may represent chronic area  scarring and granulation related to surgery from right hip replacement.

There is a fluid attenuation collection within the right anterior upper thigh which does not demonstrate increased activity and may represent postoperative changes. No suspicious sites of increased activity saw within the legs.

CT for attenuation correction: The heart enlarges. There is atherosclerosis of the aorta and coronary arteries. There appear to be postoperative changes within the posterior inferior right lower lobe. The patient is status post gastric bypass.

Colonic diverticulosis. The patient is status post bilateral hip replacement surgery.

IMPRESSION:

No abnormal areas of suspicious uptake within the head/neck, lungs nor mediastinum.

No uptake saw within abdominal or mesenteric nodes.

Increased uptake within the high left inguinal region corresponding to two small nodular densities, which may represent lymph nodes.

Increased uptake is seen laterally along the right lateral tensor fascia lata deep to an area of linear density, likely representing granulation, and had status post right hip replacement.

Small fluid collection within the ventral right thigh without evidence for increased uptake may represent a postoperative seroma.