CPT 78815Radiology

Pet image w/ct skull-thigh

CPT code 78815 represents a PET/CT imaging scan that covers the body from the skull down to the mid-thigh, combining functional metabolic imaging (PET) with detailed anatomical imaging (CT) in a single session. This comprehensive scan is commonly used to detect, stage, or monitor cancer and other metabolic diseases throughout most of the body.

Showing rates for

National Average

Base Medicare rate

$109.01

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

2.44

PE RVU (NF)

0.81

MP RVU

0.12

Total RVU

3.37

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

NCCI bundling edits

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Billing tips

Verify National Coverage Determination (NCD) 220.6 compliance before scheduling - Medicare only covers 78815 for specific cancer types and clinical indications
Impact: Non-compliance results in 100% claim denial; approximately 12-15% of PET scan denials relate to non-covered indications
Document exact anatomic coverage in the report - if imaging extends below mid-thigh to include lower extremities, use 78816 instead of 78815
Impact: Using 78816 when appropriate yields higher reimbursement and prevents downcoding; incorrect code selection causes delays and denials
Obtain prior authorization before performing the scan - most Medicare Administrative Contractors and commercial payers require pre-authorization for PET/CT
Impact: Missing authorization is the leading cause of PET/CT denials, affecting 20-30% of claims; retroactive authorization rarely granted
Bill diagnostic CT separately only when performed as a full diagnostic study with separate interpretation - the CT in 78815 is for attenuation correction and anatomic localization
Impact: Inappropriate unbundling of diagnostic CT triggers audits; legitimate separate diagnostic CT can add $100-300 when properly documented
Ensure radiopharmaceutical administration code (A9552 for F-18 FDG) is billed separately with appropriate units based on dose administered
Impact: Radiopharmaceutical represents significant additional reimbursement ($400-600 per dose) often overlooked or undercoded
Link appropriate ICD-10 diagnosis codes that match Medicare LCD requirements - use both the malignancy code and any relevant secondary codes

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 78815 in 2025?

The 2025 Medicare national average reimbursement for CPT 78815 is $109.01 for both facility and non-facility settings. This rate is based on 3.37 total RVUs (2.44 work RVU, 0.81 PE RVU, 0.12 MP RVU) multiplied by the 2025 conversion factor of 32.3465. Actual reimbursement may vary by geographic locality based on GPCI adjustments.

What is the difference between CPT codes 78815 and 78816?

CPT 78815 covers PET/CT imaging from the skull base to mid-thigh, while CPT 78816 includes imaging from skull to toe (entire body including lower extremities). Use 78816 when clinical indication requires assessment of the lower legs and feet, such as melanoma staging or evaluation for distal metastases. The anatomic coverage determines correct code selection.

Does Medicare require prior authorization for CPT 78815?

Most Medicare Administrative Contractors (MACs) require prior authorization for PET/CT scans under the Appropriate Use Criteria program. Additionally, many MACs participate in the Prior Authorization and Pre-Claim Review Initiatives for advanced imaging. Requirements vary by jurisdiction, so verify with your specific MAC and check commercial payer policies separately.

Can I bill a separate diagnostic CT with CPT 78815?

The CT component in 78815 is for attenuation correction and anatomic localization only. You may bill a separate diagnostic CT only if it is a complete diagnostic study performed with separate IV contrast, full diagnostic acquisition parameters, and a distinct formal interpretation addressing different clinical questions. Documentation must clearly support medical necessity for both studies.

What cancer types are covered by Medicare for CPT 78815?

Medicare NCD 220.6 covers PET/CT for most solid tumors and lymphomas including lung cancer, colorectal cancer, melanoma, lymphoma, esophageal cancer, head and neck cancers, and many others for initial staging, restaging, and treatment response. Notable exclusions include prostate cancer initial staging and screening in asymptomatic patients. Always verify current LCD requirements for specific indications.

How often can CPT 78815 be billed for the same patient?

Medicare typically covers PET/CT for cancer monitoring no more frequently than every 3 months unless specific clinical circumstances justify more frequent imaging (rapid progression, treatment change, clinical trial protocol). Initial staging and one restaging scan are generally covered without frequency limitations. Documentation must support medical necessity for each scan.

What are the RVU values for CPT code 78815 in 2025?

CPT 78815 has a total RVU of 3.37 in 2025, consisting of 2.44 work RVUs, 0.81 practice expense RVUs (both facility and non-facility), and 0.12 malpractice RVUs. These values are published in the CMS Physician Fee Schedule RVU25A file released December 23, 2024.