78300 – Bone and/or joint imaging; limited area
78305 – Bone and/or joint imaging; multiple areas
78306 – Bone and/or joint imaging; whole body – Average fee amount $275
78315 – Bone and/or joint imaging; 3 phase study
78320 – Bone and/or joint imaging; tomographic (SPECT)
Indications and Limitations of Coverage and/or Medical Necessity
Bone and/or joint imaging, also known as a bone scan, skeletal scintigraphy, or a radionuclide bone scan is a nuclear medicine study utilizing an intravenous injection of a technetium-99m phosphonate radiopharmaceutical which localizes in bone with intensity proportional to the degree of metabolic activity present. This diagnostic study records the distribution of this radioactive tracer in the skeletal system in planar (two-dimensional) and/or tomographic (three-dimensional) images normally 2-4 hours after the injection of the radiopharmaceutical agent.
A whole body bone scan produces planar images of the skeleton including anterior and posterior views of the axial skeleton. Anterior and/or posterior views of the appendicular skeleton are also obtained. Additional views may be obtained as needed. The limited bone scan records images of only a portion of the skeleton.
Bone single photon emission computed tomography (SPECT) produces a tomographic image of a portion of the skeleton. This technique increases diagnostic accuracy by improving sensitivity, providing more precise localization of the radiopharmaceutical, and allowing improved visualization of subtle abnormalities.
Three-phase imaging, also known as multiphase bone scintigraphy consists of blood flow images, immediate images and delayed images and is utilized to distinguish skeletal from soft-tissue infection. The blood flow images consist of a dynamic sequence of planar images of the area of greatest interest obtained as the tracer is injected. The immediate (blood pool) images consist of one or more static planar images of the areas of interest, obtained within 10 minutes after injection of the tracer. Delayed images may be limited to the areas of interest or may include the whole body, may be planar or tomographic, and are usually acquired 2 to 5 hours after injection. Further additional images obtained up to 24 hours following the tracer injection may be obtained if necessary.
Bone and/or joint imaging will be considered medically reasonable and necessary for the following indications:
· Extraskeletal primary malignancies for the presence of metastatic disease. The application of imaging in these patients include initial staging, protocol monitoring in response to chemotherapy and decision to change therapy, radiation therapy for treatment field planning and response to radiation therapy, and detection of areas at risk for pathological fracture.
· Primary malignant bone tumors when metastasis is suspected. Normally, plain radiographs, CT and MRI are a better diagnostic test to portray the tumor margins in bone and allow assessment of soft tissue extent. However, a whole body scan is appropriate to assess osseous metastasis.
· Benign bone tumors including osteoid osteomas, osteochondromas, chondroblastomas and enchondromas.
· Skeletal trauma to evaluate the presence of occult fractures when the initial standard radiographic procedure is normal and the clinical presentation is highly suspicious of fracture.
· Assessing the full extent of injury in patients with multiple injuries.
· Athletic injuries to evaluate for stress fractures and shin splints.
· Determine bone viability in infarction, osteonecrosis, and grafts.
· Osteomyelitis. The evaluation of osteomyelitis is performed utilizing the triple-phase bone scan. This technique is used to differentiate osteomyelitis from cellulitis.
· Diagnosis and evaluation of musculoskeletal infections to rule out bone involvement. A triple-phase bone scan is utilized for this indication.
· Metabolic bone disease such as osteoporosis and Paget’s Disease when the results of the bone scan will be used to guide treatment.
· Diagnosis and evaluation of reflex sympathetic dystrophy. The evaluation of reflex sympathetic dystrophy is performed utilizing the triple-phase bone scan.
· Evaluate a prosthetic joint for loosening or infection.
· Unexplained musculoskeletal pain when the initial standard radiographic procedure fails to determine the etiology and a musculoskeletal etiology is suspected.
· Evaluation of abnormal radiographic findings or abnormal laboratory findings demonstrating skeletal involvement.
· Determine the distribution of osteoblastic activity prior to therapy with strontium-89.
Note: as indicated above, the triple-phase bone scan is normally utilized to evaluate, but not limited to: osteomyelitis; diagnose and evaluate musculoskeletal infections to rule out bone involvement; and to diagnose and evaluate reflex sympathetic dystrophy. Therefore, it is expected that this technique is utilized to evaluate these conditions.
Skeletal scintigraphy is a sensitive marker of both osteoarthritis and rheumatoid arthritis. Numerous attempts have been made over the last two decades to develop scintigraphic techniques for staging the severity of arthritis and assessing response to therapy. These have been largely unsuccessful, and skeletal scintigraphy, although not common, may be used to evaluate arthritis in current clinical practice.
It is expected that a whole body scan (procedure code 78306) is performed only when an evaluation of the entire skeletal system is necessary, such as the evaluation for metastatic disease, or for the evaluation of localized pain of unknown etiology. A limited or muliple area body scan is medically necessary when the patient’s signs, symptoms, or condition is limited to a certain body area. For example, it is expected that a limited bone scan be performed on patients with a stress fracture of the foot. A multiple area body scan is necessary in conditions in which more than one body area is affected, however, a total assessment of the skeletal system is not needed. A triple-phase body scan is medically necessary for the assessment of the skeletal system to differentiate a skeletal infection versus a soft tissue infection.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12 – Hospital Inpatient (Medicare Part B only)
13 – Hospital Outpatient
14 – Hospital – Laboratory Services Provided to Non-patients
22 – Skilled Nursing – Inpatient (Medicare Part B only)
23 – Skilled Nursing – Outpatient
85 – Critical Access Hospital
The basic bone scan will be performed and images checked before the patient leaves. If additional oblique or lateral images or SPECT images are needed they will be performed.
Confirm bone or joint origin of pain
Detection of bone infarction
Pre-bone marrow transplant
elevated alkaline phosphatase
Screening for multifocal bone lesions in sydromes
(for example: Langerhan Cell Histiocytosis, Ollier’s disease, osteochondromatosis, Mafucci syndrome, Fibrous Dysplasia)
Tumors: primary bone tumors or evaluation for metastases
Procedure Code Procedure Code Description
78306 whole body
Whole body is head to toe (almost) for bone scan imaging (Procedure code 78306) and in Procedure code ; for PET (Procedure code 78812 78815) i th b f k ll t id thi h f 27 78812, 78815) is the base of skull to mid thigh, for PET (Procedure code 78813, 78816) is top of skull to substantially below the knees usually extending to the feet, for thyroid cancer (Procedure code 78018) head to below pelvis
78315 – Bone and/or joint imaging; 3 phase study
– Even though a whole body bone scan was performed, it is included and not separately coded. The static bone scan “phase” can be limited, multiple areas, or whole body.
– SNM says that when a whole body scan is performed as part of a 3 phase study code either 78306 OR 78315.
Payments for Radionuclides
The TC RVUs for nuclear medicine procedures (Procedure codes 78XXX for diagnostic
nuclear medicine, and codes 79XXX for therapeutic nuclear medicine) do not include the radionuclide used in connection with the procedure. These substances are separately billed under codes A4641 and A4642 for diagnostic procedures, and code 79900 for therapeutic procedures and are paid on a “By Report” basis depending on the substance used. In addition, Procedure code 79900 is separately payable in connection with certain clinical brachytherapy procedures. (See §70.4 for brachytherapy procedures).
Carriers must make separate payment under code J1245 for pharmacologic stressing
agents used in connection with nuclear medicine and cardiovascular stress testing
procedures furnished to beneficiaries in settings in which TCs are payable. Such an agent is classified as a supply and covered as an integral part of the diagnostic test. However, carriers pay for code J1245 under the policy for determining payments for “incident to” drugs.
FI Payment for IV Persantine SNF-533.1.I
The FIs pay drug IV Persantine based on the drug pricing methodology when used in
conjunction with nuclear medicine and cardiovascular stress testing procedures furnished to SNF outpatients. Separate drug pricing methodology payments for IV Persantine is made in addition to payments made for the procedure. SNFs bill HCPCS code J1245 (injection, dipyridamole, per 10 mg.) with revenue code 0636.
FI Payment for Adenosine SNF-533.3
The drug adenosine is paid based on the drug payment methodology when used as a pharmacologic stressor for other diagnostic testing. Separate based payment for adenosine will be made in addition to payments made for the procedure for SNF Part B patients. When billing for adenosine, HCPCS code J0150 (Injection, adenosine, 6 mg.)
should be reported with revenue code 0636.
Application of Multiple Procedure Policy (Procedure code Modifier “-51”)
Carriers must apply the multiple procedure reduction to the following nuclear medicine
diagnostic procedures: codes 78306, 78320, 78802, 78803, 78806, and 78807.
Generation and Interpretation of Automated Data
Payment for Procedure codes 78890 and 78891 is bundled into payments for the primary procedure.
Question: Can I code and bill for two oncology PET procedures on the same date of service (SDOS)?
SNM comment: The answer is both no and yes. Procedure guidance is clear in the Procedure code parenthetical following the PET tumor codes: “report 78811-78816 only once per imaging session”. Therefore, providers may use one Procedure code in the series 78811-78816 when billing PET tumor imaging.
” NO “: – As an example, it would not be appropriate to code and bill for both a limited bone scan (Procedure code78300) and a whole body study (Procedure code 78306). The limited study is considered part of the whole body study. In general, when the AMA RUC (RUC stands for Relative Update Committee) values Procedure codes, it does so on the basis of a typical study (including additional views). Providers should choose the appropriate code to reflect the body area imaged. Even if the brain is included in an extended “skull base to mid thigh” study, the code for brain imaging should not be used in addition to Procedure code 78812 or 78815.
MULTIPLE NUCLEAR MEDICINE DIAGNOSTIC PROCEDURES
The multiple surgery rules apply to the following combination of codes for services of the same provider (or group practice) on the same day:
A. 78306, bone imaging; whole body, and 78320, bone imaging; SPECT;
B. 78802, radionuclide localization of tumor; whole body, and 78803 tumor localization; SPECT; and
C. 78806, radionuclide localization of abscess; whole body, and 78807, radionuclide localization of abscess; SPECT.
Question: How is a three-phase, whole-body bone study reported?
Answer: A three-phase, whole-body bone study is reported with CPT 78315, Bone and/or joint imaging; 3 phase study. A three-phase study includes initial vascular flow followed by blood pool imaging and followed by delayed statis bone scans. Therefore, it is not appropriate to report a planar, limited (CPT 78300); multiple areas (CPT 78305); or whole-body (CPT 78306) bone scan or a non-cardiac vascular flow study (CPT 78445) in conjunction with a three-phase bone study, as they are all considered to be part of the three-phase bone study. If an additional delayed phase (referred to as a four-phase study) is performed, it is also considered included in CPT code 78315 and not reported separately. This three-phase with a whole body combination should be rate, as there are few clinical situations in which this comibination would be considered medically necessary.
While the difference between the first and the second reference is subtle, conceptually they both reinforce the same concept: Only a single code should be submitted when performing whole-body and three-phase bone imaging on the same patient during the same encounter and that the three-phase code (78315) supersedes that of the whole-body imaging (78306).