CPT 78814Radiology

Pet image w/ct lmtd

CPT 78814 covers a limited PET scan combined with a CT scan, used to detect cancer, evaluate heart function, or assess brain disorders. The 'limited' designation means the scan covers a specific body region rather than the full body.

Showing rates for

National Average

Base Medicare rate

$97.36

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

2.2

PE RVU (NF)

0.71

MP RVU

0.1

Total RVU

3.01

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

NCCI bundling edits

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Billing tips

Clearly document the specific anatomic region covered and clinical rationale for 'limited' rather than complete PET/CT to support 78814 instead of 78815
Impact: Prevents upcoding allegations and ensures appropriate $97.36 reimbursement rather than incorrect billing of higher-valued codes
Verify patient NPO status (4-6 hours) and glucose levels (<200 mg/dL) are documented in medical record prior to FDG administration
Impact: Prevents technical denials and supports medical necessity; missing documentation causes 15-25% of initial claim denials
Bill facility and non-facility rates correctly based on place of service; 78814 has identical rates ($97.36) but documentation differs
Impact: Ensures compliance with site-of-service requirements; prevents recoupment audits averaging $2,500-$5,000 per facility
When billing split/shared services, use appropriate modifiers and ensure both technical and professional components total to 3.01 RVUs
Impact: Prevents overpayment recovery; improper modifier use accounts for 30% of PET/CT audit findings
Verify LCD coverage requirements for specific radiotracer used; Medicare covers FDG PET/CT for specific oncologic indications only
Impact: Non-covered indications result in 100% denial; advance beneficiary notice (ABN) required when coverage uncertain
Document the CT technical parameters showing 'limited' acquisition (reduced field of view, single body region) versus full diagnostic CT
Impact: Supports accurate code selection and prevents downcoding; inadequate documentation causes $40-60 reduction in reimbursement

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Frequently asked questions

What is the difference between CPT 78814 and 78815?

CPT 78814 covers PET with limited CT (focused on specific body region), while 78815 includes PET with full diagnostic CT (skull to mid-thigh or complete anatomic coverage). The limited designation in 78814 means reduced anatomic coverage and lower radiation dose, with 2025 Medicare reimbursement of $97.36 versus higher rates for 78815.

How much does Medicare pay for CPT 78814 in 2025?

Medicare pays $97.36 for CPT 78814 in 2025 based on 3.01 total RVUs (2.2 work RVU, 0.71 PE RVU, 0.1 MP RVU) multiplied by the conversion factor of 32.3465. This rate applies to both facility and non-facility settings for this code.

Can you bill CPT 78814 with modifier 26 or TC?

Yes, CPT 78814 can be split using modifier 26 (professional component only for physician interpretation) or modifier TC (technical component only for equipment and staff). This is common when the imaging center owns equipment but contracts with outside radiologists for interpretation, or in academic settings with split billing arrangements.

What diagnosis codes support medical necessity for CPT 78814?

Medical necessity for 78814 depends on Local Coverage Determinations, but commonly covered diagnoses include malignant neoplasms (C00-C96 series), post-treatment surveillance for specific cancers (lung, colorectal, lymphoma, melanoma), and evaluation of solitary pulmonary nodules. Cardiac and neurologic indications have more restrictive coverage criteria.

How often can you bill CPT 78814 for the same patient?

Medicare frequency limitations for 78814 typically allow one scan every 3-4 months for most cancer surveillance, with specific intervals varying by cancer type per Local Coverage Determinations. More frequent scanning requires documentation of clinical change, symptoms, or treatment response evaluation. Initial staging and subsequent restaging may have different frequency allowances.

What are the documentation requirements to bill CPT 78814?

Required documentation includes clinical indication with diagnosis code, radiotracer type and dose, patient preparation (NPO status, glucose level), specific anatomic region scanned with defined boundaries, CT technical parameters showing limited acquisition, complete interpretation report correlating PET and CT findings, and ordering physician information with clinical question addressed.

Is prior authorization required for CPT 78814?

Prior authorization requirements vary by payer. Medicare Advantage plans frequently require prior auth for PET/CT services. Traditional Medicare does not require prior authorization but may require Advance Beneficiary Notice (ABN) for potentially non-covered indications. Commercial payers increasingly require precertification, with denials common when authorization not obtained before service.