CPT 78816Radiology

Pet image w/ct full body

CPT code 78816 represents a combined PET and CT scan of the entire body, used to detect cancer, evaluate treatment response, or identify metabolic abnormalities throughout the body in a single imaging session.

Showing rates for

National Average

Base Medicare rate

$109.65

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

2.5

PE RVU (NF)

0.79

MP RVU

0.1

Total RVU

3.39

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

NCCI bundling edits

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Billing tips

Verify coverage under National Coverage Determination (NCD) 220.6 for specific cancer type before scheduling; many cancer indications require specific clinical scenarios or are covered only under Coverage with Evidence Development
Impact: Prevents denials worth $109.65 per claim; non-covered indications result in 100% payment loss without proper ABN
Document the specific cancer diagnosis with ICD-10 code in medical necessity statement; include prior imaging results and how PET/CT will change management decisions
Impact: Reduces denial rate by 40-60% based on Medicare contractor data; inadequate medical necessity is the #1 denial reason
Do not bill 78816 with same-day diagnostic CT of the same anatomic region; the CT portion of PET/CT is for attenuation correction and localization only, not diagnostic interpretation
Impact: Prevents bundling denials and potential fraud allegations; unbundling can trigger RAC audits with recoupment demands
For initial treatment strategy, restaging, or treatment monitoring in lung cancer, ensure documentation meets CMS criteria (initial staging, suspected recurrence, or after 3 cycles of chemotherapy)
Impact: Compliance with NCD 220.6.17 prevents denials; non-compliant timing results in automatic denial of $109.65
Bill professional and technical components separately when appropriate split-billing arrangement exists between reading physician and imaging facility
Impact: Optimizes revenue distribution; improper modifier use can delay payment 15-30 days pending clarification
Ensure radiopharmaceutical administration (CPT 78018 or A9552 for F-18 FDG) is billed separately with appropriate HCPCS codes for the tracer supply

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 78816 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 78816 is $109.65 for both facility and non-facility settings, based on 3.39 total RVUs and a conversion factor of 32.3465. This represents the professional component payment; technical component and radiopharmaceutical costs are billed separately.

How many times will Medicare cover PET/CT scans for cancer patients?

Medicare typically covers PET/CT up to three times per cancer episode under NCD 220.6: once for initial treatment strategy, once for subsequent treatment strategy after completion of initial treatment, and once for suspected recurrence or treatment monitoring. Additional scans may be covered under Coverage with Evidence Development (CED) programs or for specific cancer types with expanded coverage criteria.

What is the difference between CPT 78816 and 78815?

CPT 78816 includes both PET imaging and CT for attenuation correction/localization in a single session (PET/CT fusion), while 78815 is PET imaging only without CT. Code 78816 is preferred for most oncologic indications as it provides superior anatomic localization and is the standard of care for cancer imaging, though it requires hybrid PET/CT equipment.

Can CPT 78816 be billed with a diagnostic CT on the same day?

Generally no - the CT component of 78816 is for attenuation correction and anatomic localization only, not diagnostic interpretation. Billing a separate diagnostic CT of the same body region on the same day typically results in bundling denials. If a separate diagnostic-quality CT is medically necessary for different clinical indication, detailed documentation and modifier 59 may be required.

What diagnosis codes are required for Medicare coverage of CPT 78816?

Coverage depends on the specific cancer type listed in NCD 220.6, including lung cancer (C34.x), colorectal cancer (C18.x-C20), lymphoma (C81.x-C85.x), melanoma (C43.x), head and neck cancers (C00.x-C14.x), and many others. The diagnosis code must support the clinical indication (initial staging, restaging, or treatment monitoring) and match approved scenarios in the NCD.

What are the work RVUs for CPT code 78816?

CPT 78816 has 2.5 work RVUs, 0.79 practice expense RVUs (both facility and non-facility), and 0.1 malpractice RVUs, totaling 3.39 RVUs in 2025. This reflects the physician work involved in image interpretation and correlation with clinical data, but does not include the technical component of performing the scan.

Do I need an Advance Beneficiary Notice (ABN) for PET/CT scans?

Yes, an ABN is strongly recommended when ordering PET/CT for indications not clearly covered under NCD 220.6 or when frequency limits may be exceeded. Without a properly executed ABN, the facility cannot bill the patient if Medicare denies the claim, resulting in complete loss of payment. ABNs should be obtained before the procedure when coverage is uncertain.