CPT 78813Radiology

Pet image full body

CPT code 78813 covers a full-body PET (Positron Emission Tomography) scan, an advanced imaging test that helps doctors detect cancer, evaluate heart disease, or assess brain disorders by tracking radioactive tracers in the body.

Showing rates for

National Average

Base Medicare rate

$87.34

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

PE RVU (NF)

0.62

MP RVU

0.08

Total RVU

2.7

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

NCCI bundling edits

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Billing tips

Always verify LCD (Local Coverage Determination) compliance for your MAC before scheduling - PET imaging has strict coverage criteria including approved cancer types and specific clinical scenarios
Impact: Prevents denials worth $87.34+ per study; pre-authorization compliance reduces denial rate by 60-80%
Document the specific cancer histology and clinical indication matching LCD requirements - generic 'cancer staging' is insufficient for most MACs
Impact: Medical necessity denials account for 40-50% of PET claim rejections; proper documentation increases first-pass acceptance rate
Bill 78813 as a standalone code only when not combined with CT - if PET/CT performed together, use 78814 or 78815 instead to avoid unbundling issues
Impact: Incorrect code selection can result in 100% payment denial or recoupment; 78814 pays significantly higher for combined studies
Verify patient has met minimum uptake time requirements (typically 60-90 minutes for FDG) and document any deviations with clinical justification
Impact: Technical denials for protocol non-compliance; proper timing affects diagnostic quality and defensibility in audits
For Medicare patients, confirm the study falls within the limited coverage list or qualifies under Coverage with Evidence Development (CED) for newer indications
Impact: Medicare covers 78813 for specific solid tumors only; billing for non-covered indications results in beneficiary liability issues
Append modifier 26 or TC appropriately based on your billing arrangement - global billing (no modifier) only appropriate when practice owns equipment and provides interpretation

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 78813 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 78813 is $87.34 for both facility and non-facility settings. This represents the technical component only. The total RVU is 2.7, consisting of 2.0 work RVU, 0.62 practice expense RVU, and 0.08 malpractice RVU, multiplied by the 2025 conversion factor of 32.3465.

What is the difference between CPT codes 78813, 78814, and 78815?

CPT 78813 is PET imaging alone (full body), 78814 is PET with concurrently acquired CT for attenuation correction and anatomic localization (limited CT), and 78815 is PET with full diagnostic CT. When PET and CT are performed together in a single session, you must use 78814 or 78815 rather than billing them separately. Using 78814/78815 appropriately results in higher reimbursement and avoids unbundling violations.

Does Medicare require prior authorization for CPT 78813?

Prior authorization requirements for 78813 vary by Medicare Administrative Contractor (MAC) and commercial payers. Many MACs and Medicare Advantage plans require prior authorization for PET imaging. Additionally, the study must meet Local Coverage Determination (LCD) criteria for the specific cancer type and clinical scenario. Always verify requirements with the specific payer before scheduling.

What cancer types are covered by Medicare for PET imaging with 78813?

Medicare covers 78813 for specific solid tumor cancers including lung, colorectal, lymphoma, melanoma, head and neck, cervical, esophageal, breast, and thyroid cancers for initial staging, restaging, and monitoring treatment response. Coverage is limited to FDG-PET and requires compliance with National Coverage Determination (NCD) 220.6 and applicable LCDs. Not all cancer types are covered, and specific clinical criteria must be met.

How often can CPT 78813 be billed for the same patient?

Medicare typically covers PET imaging at clinically appropriate intervals based on treatment status and clinical changes. Common scenarios include initial staging, post-treatment restaging (usually after therapy completion), and surveillance for recurrence when clinical findings suggest disease progression. Most LCDs don't specify exact time intervals but require documentation of clinical necessity for each study. Routine surveillance without symptoms is generally not covered.

Can CPT 78813 be billed with modifier 26 for professional component only?

Yes, modifier 26 should be appended to 78813 when billing only for the physician's professional interpretation and report, without the technical equipment and staff costs. This is common when a radiologist interprets studies performed at a hospital or imaging center that bills separately for the technical component (modifier TC). The facility and professional components are reimbursed separately in this split-billing scenario.

What documentation is required to avoid denials for CPT 78813?

Required documentation includes: specific cancer histology and stage matching LCD criteria, clinical indication (staging, restaging, or surveillance with specific rationale), relevant history including prior treatments and imaging, radiopharmaceutical details, technical parameters, detailed interpretation with SUV values, correlation with prior studies, and clear impression addressing the clinical question. Medical necessity must be clearly established, particularly for surveillance imaging or non-standard indications.