Is the technique of PET/CT with the CT scan used for anatomical localization and attenuation correction from skull base to mid-thigh enough information for the coder to assign code 78815 for the following report? PROCEDURE: PET/CT TUMOR IMAGE SKULL THIGH INITIAL INDICATIONS: Lung and breast cancer; Weight loss; Mediastinal adenopathy GLUCOSE LEVEL: 93mg/dL @ 1400. F18 - FDG FINAL ASSAY:12.12mCi RADIATION: Total Dose Length Product (DLP): 560mGy.cm TECHNIQUE: After obtaining the patient's consent, F-18 FDG was administered intravenously. PET/CT imaging was performed using a dedicated integrated PET/CT scanner. FINDINGS: HEAD/NECK: Normal. No pathologic FDG activity. LUNGS: Normal. No pathologic FDG activity. No suspicious nodules on CT imaging. MEDIASTINUM/HILA: Hypermetabolic left hilar lymph node corresponding with enlarged lymph node. Max SUV 4.4. No additional enlarged hypermetabolic lymph nodes. CHEST WALL/AXILLA: Normal. No pathologic FDG activity. ABDOMEN: Normal. No pathologic FDG activity. PELVIS: Normal. No pathologic FDG activity. BONES: Normal. No pathologic FDG activity. CONCLUSION: Redemonstration of enlarged left hilar lymph node with hypermetabolic activity, consistent with metastatic involvement. No additional enlarged or hypermetabolic lymph node ...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This coding-focused article reviews a PET/CT oncology imaging report and explains the kinds of documentation elements a coder looks for when evaluating whether the study supports a specific PET/CT billing code. It is aimed at coding professionals, auditors, and clinical documentation staff who work with nuclear medicine and oncology imaging records. The article also notes that the radiopharmaceutical may be billed separately when documented appropriately.

Why This Topic Matters

PET/CT claims can be affected by incomplete or inconsistent documentation. Understanding the minimum report elements and documentation quality issues helps coders, auditors, and providers support accurate charge capture and compliant claim submission.

Article Sections

1. Report review and coding question

   Introduces the imaging report under review and the coding concern being evaluated. The section frames the discussion around documentation completeness for PET/CT oncology imaging.

2. Technical documentation considerations

   Discusses the types of report elements expected in the technique and clinical documentation. The focus is on completeness of the imaging record and the reliability of autogenerated exam wording.

3. Coding and reporting implications

   Summarizes the coding relevance of the documentation issues and the need for report revision when key information is unclear. It also mentions separate billing for the radiopharmaceutical when appropriate.

Codes Discussed

• CPT: 78815

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