Coding and documentation needed for post-treatment PET scan(s)

Q.

Recently we began receiving increased denials from Medicare for CPT^® code 78815-PS as “non-covered.” It appears that we now have to report two diagnosis codes for these claims. Can you help me understand why this might be occurring?

A.

Medicare’s Positron Emission Tomography (PET) policy states: “NOTE: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D, or R diagnosis codes.” Medicare does not cover “surveillance” or “watchful waiting” PETs after treatment is over, so, you must have a reason for the exam, not just checking every once in a while to see if there is recurrence. Because of that, if you report a “Personal history” of cancer diagnosis code, then you have to have another diagnosis code to indicate why you are doing the PET. You need to show that now they have another type of cancer (C or D code), or a clinical indication indicating possible recurrence (R code).