CPT 78580Radiology

Lung perfusion imaging

CPT code 78580 covers lung perfusion imaging, a nuclear medicine scan that shows blood flow through the lungs to detect clots, blockages, or other circulation problems.

Showing rates for

National Average

Base Medicare rate

$206.69

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.74

PE RVU (NF)

5.57

MP RVU

0.08

Total RVU

6.39

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always verify if ventilation scan (78579) was also performed; V/Q scans are commonly ordered together and should be billed with appropriate modifiers to prevent bundling
Impact: Prevents loss of $200+ in reimbursement when ventilation component is unbundled inappropriately
Document specific clinical indication beyond 'rule out PE' - include Wells score, PERC criteria, or specific contraindication to CT angiography to strengthen medical necessity
Impact: Reduces denial rate by 30-40% for medical necessity challenges
Verify that D-dimer results (if obtained) are documented in medical record when ordering for suspected PE; negative D-dimer may trigger medical necessity denials
Impact: Prevents automatic denials from payers requiring D-dimer documentation as first-line screening
Bill facility vs non-facility rate appropriately; both are $206.69 for 2025, but place of service code must match actual location (22 for outpatient hospital, 11 for office)
Impact: Ensures accurate claims processing and prevents place-of-service mismatches
Capture radiopharmaceutical administration separately with CPT 79101 when appropriate billing structure allows; verify payer policy on separate billing
Impact: May generate additional $20-40 when payer permits separate radiopharmaceutical administration billing
Link appropriate ICD-10 codes emphasizing clinical suspicion: I26.99 (pulmonary embolism), R06.02 (shortness of breath), Z86.718 (personal history of PE) to support medical necessity
Impact: Proper diagnosis linkage reduces denial rate by 25-35% for medical necessity reviews

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 78580 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 78580 is $206.69 for both facility and non-facility settings, based on 6.39 total RVUs and a conversion factor of 32.3465.

Can CPT 78580 and 78579 be billed together on the same day?

Yes, CPT 78580 (perfusion) and 78579 (ventilation) are commonly billed together for a complete V/Q scan. Use modifier 59 on the secondary code to prevent inappropriate bundling and ensure both components are reimbursed separately.

What documentation is required to support medical necessity for CPT 78580?

Medical necessity requires documented clinical suspicion of pulmonary embolism with risk stratification scores (Wells, PERC, Geneva), contraindications to CT angiography if applicable, relevant symptoms, and supporting laboratory values like D-dimer when obtained.

How do I bill CPT 78580 with modifier 26 vs TC?

Use modifier 26 when billing only the professional component (physician interpretation) and modifier TC for the technical component (equipment, supplies, technologist). The facility bills TC while the interpreting physician bills 26 when components are split.

What are the most common denial reasons for CPT 78580?

Common denials include lack of medical necessity when CT angiography is preferred, bundling issues when billed with 78579 without proper modifiers, frequency limitations for repeat scans, and incomplete documentation of clinical indication or interpretation.

What ICD-10 codes support medical necessity for lung perfusion imaging?

Primary supporting diagnoses include I26.99 (pulmonary embolism without acute cor pulmonale), R06.02 (shortness of breath), R07.89 (chest pain), Z86.718 (personal history of PE), and I27.20 (pulmonary hypertension). Document specific clinical presentation clearly.

Is prior authorization required for CPT 78580?

Prior authorization requirements vary by payer. Many Medicare Advantage plans and commercial insurers require pre-authorization for nuclear medicine studies. Verify specific payer policies before scheduling, as retroactive denials are common without proper authorization.