CPT 78812Radiology

Pet image skull-thigh

CPT code 78812 covers a PET (Positron Emission Tomography) scan that images from the skull down to the thigh, used to detect cancer, assess treatment response, or identify areas of abnormal metabolic activity in the upper body and torso.

Showing rates for

National Average

Base Medicare rate

$85.72

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

1.93

PE RVU (NF)

0.64

MP RVU

0.08

Total RVU

2.65

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

NCCI bundling edits

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Billing tips

Verify exact anatomical coverage documented matches skull-to-thigh boundaries; if imaging extends to full body, use 78813 instead to avoid underbilling
Impact: Using wrong PET code can result in $100+ reimbursement differences; 78813 typically reimburses 15-20% higher
Confirm medical necessity documentation includes specific cancer diagnosis or clinical indication; payers deny PET scans without oncologic justification
Impact: Prevents 100% denial ($85.72 lost revenue per claim); prior authorization approval rates increase from 60% to 95% with proper documentation
Bill with appropriate modifier 26 if only interpreting images acquired at different facility; never bill global code without owning technical component
Impact: Incorrect global billing triggers recoupment of full payment minus professional component, typically $40-50 per claim
Document time interval from previous PET scan and clinical justification for repeat imaging; Medicare LCD policies restrict frequency
Impact: Scans performed within restricted timeframes face 70-80% denial rate unless exception criteria documented
Link to specific ICD-10 codes for known malignancy (C codes) rather than screening or symptoms; PET is not a screening tool for asymptomatic patients
Impact: Proper diagnosis coding increases first-pass acceptance rate by 35%; screening indications result in automatic denials
Ensure radiopharmaceutical administration is billed separately with appropriate A-codes (A9552 for FDG) by technical component provider
Impact: Radiopharmaceutical represents $800-1200 in additional reimbursement; must be billed by facility/technical provider, not interpreting physician

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 78812 in 2025?

The 2025 Medicare national average reimbursement rate for CPT code 78812 is $85.72 for both facility and non-facility settings. This represents the professional component interpretation fee; technical component costs are billed separately by the facility performing the scan.

What is the difference between CPT codes 78812 and 78813?

CPT 78812 covers PET imaging from skull to thigh, while 78813 covers skull to mid-thigh. The anatomical endpoint differs slightly, with 78812 extending further down the leg. Documentation must specify exact anatomical coverage to support the correct code selection.

How often can CPT 78812 be billed for the same patient?

Medicare LCD policies typically allow PET scans for initial staging, one subsequent scan for treatment monitoring (usually after 2-3 cycles of chemotherapy), and post-treatment surveillance scans at specific intervals. Frequency restrictions vary by diagnosis and payer; scans performed more frequently than LCD guidelines require exceptional documentation of medical necessity.

What diagnosis codes are required for CPT 78812 to be covered?

CPT 78812 requires specific cancer diagnosis codes (C-codes for malignant neoplasms) or documented suspicion of malignancy with supporting clinical findings. Common covered diagnoses include lymphoma (C81-C86), lung cancer (C34), breast cancer (C50), and melanoma (C43). Screening codes or symptom-only codes typically result in denials.

Can CPT 78812 be billed with modifier 26 for professional component only?

Yes, modifier 26 should be appended when the physician only interprets the PET scan images acquired at a separate facility. The facility performing the technical component bills with modifier TC. When billing globally (both professional and technical components), no modifier is needed if the same entity owns both components.

What are the RVU values for CPT code 78812 in 2025?

For 2025, CPT 78812 has a Work RVU of 1.93, non-facility PE RVU of 0.64, facility PE RVU of 0.64, and MP RVU of 0.08, totaling 2.65 RVUs. These values multiplied by the 2025 conversion factor of 32.3465 determine the Medicare payment rate.

Does CPT 78812 require prior authorization from Medicare or commercial payers?

Prior authorization requirements vary by payer and region. Medicare Advantage plans frequently require prior authorization for PET scans, while traditional Medicare typically does not but applies retrospective medical necessity reviews. Most commercial payers require prior authorization with submission of clinical indication, diagnosis, and treatment plan to specialized radiology benefit managers.