Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302, 12501, 12301, 12201
Contractor Type:
MAC Part A & B
Article Information
Article Database ID Number
A47551
Article Type
Article
Key Article
No
Article Title
National Coding Determination (NCD) Article for Positron Emission Tomography (PET) Scans
Contractor’s Determination Number
A47551
Primary Geographic Jurisdiction
Pennsylvania, Maryland, District of Columbia, DELAWARE
Original Article Effective Date
07/11/2008
Article Revision Effective Date
08/01/2008
Article Ending Effective Date
N/A
Article Text
As per NCD 220.6, the Centers for Medicare & Medicaid Services (CMS) made the following determinations regarding the Positron Emission Tomography (PET) Scans.
The procedure codes listed for PET scans represent the global service. Therefore, providers performing only the technical or professional component of the test should use modifier TC or 26, respectively.
FDG PET scans performed in the context of a CMS-approved practical clinical trial utilizing a specific protocol to demonstrate the utility of FDG PET in the diagnosis and treatment of disease should be reported with the QR modifier through 12/31/2007. Beginning January 1, 2008, these should be reported with the new Q0 modifier (number "0", not letter "O".)
PET with concurrently acquired CT is reported with procedure codes 78814-78816 as appropriate. These codes should not be reported for PET scans performed on a non-hybrid scanner.
If a PET scan is obtained and, on the same date of service, diagnostic CT scan(s) are obtained at a separate session, then both the PET scan and the CT scan(s) may be coded individually. If a PET/CT study is performed concurrently on a hybrid PET/CT scanner and an additional diagnostic CT scan is also obtained non-concurrently, it is appropriate to code the PET/CT scan and the diagnostic CT scan(s) separately (whether the diagnostic CT scans are performed on a hybrid PET/CT scanner or on a dedicated CT scanner). To further clarify this, the CT component of a PET/CT scan is for concurrently obtained CT scans for attenuation correction and localization and does not include any additional diagnostic CT studies that may be requested.
When a diagnostic CT scan is performed concurrently with a PET scan, the appropriate PET scan and the appropriate diagnostic CT code may be reported. If a medically necessary diagnostic CT is performed non-concurrently with a PET/CT scan, either on the PET/CT scanner or on an independent CT scanner, the appropriate PET/CT procedure code and the diagnostic CT study(s) code may be reported.
It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted.
As per Change Request 5665, dated 07/20/2007, CPT code 78609 is a non-covered service (effective date retroactive to 01/28/2005). Also, HCPCS code A4641 is not an applicable tracer for PET scans, and was removed from the code list effective 01/01/2008.
Bill Type Codes
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
18x | Hospital-swing beds |
21x | SNF-inpatient, Part A |
22x | SNF-inpatient or home health visits (Part B only) |
23x | SNF-outpatient (HHA-A also) |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
Revenue Codes
0404 | Other imaging services-positron emission tomography (eff 10/94) |
CPT/HCPCS Codes
| ||||||||||||||||||||||||||||
The following procedure codes are non-covered by Medicare:
|
ICD-9 Codes that Support Medical Necessity
Medicare is establishing the following limited coverage for CPT/HCPCS codes 78459, 78491, and 78492:
MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE | |
ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE | |
ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE | |
ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE | |
ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE | |
ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE | |
ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE | |
TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE | |
SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE | |
ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE | |
ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE | |
POSTMYOCARDIAL INFARCTION SYNDROME - INTERMEDIATE CORONARY SYNDROME | |
411.81 | ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION |
411.89 | OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER |
412 | OLD MYOCARDIAL INFARCTION |
ANGINA DECUBITUS - PRINZMETAL ANGINA | |
413.9 | OTHER AND UNSPECIFIED ANGINA PECTORIS |
CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART | |
ANEURYSM OF HEART (WALL) - DISSECTION OF CORONARY ARTERY | |
414.19 | OTHER ANEURYSM OF HEART |
414.2 | CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY |
OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE - CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED | |
424.1 | AORTIC VALVE DISORDERS |
ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED | |
426.0 | ATRIOVENTRICULAR BLOCK COMPLETE |
LEFT BUNDLE BRANCH HEMIBLOCK - RIGHT BUNDLE BRANCH BLOCK | |
BUNDLE BRANCH BLOCK UNSPECIFIED - OTHER BILATERAL BUNDLE BRANCH BLOCK | |
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - PAROXYSMAL TACHYCARDIA UNSPECIFIED | |
ATRIAL FIBRILLATION - ATRIAL FLUTTER | |
VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER | |
427.5 | CARDIAC ARREST |
427.69 | OTHER PREMATURE BEATS |
CONGESTIVE HEART FAILURE UNSPECIFIED - LEFT HEART FAILURE | |
UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART FAILURE | |
UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC DIASTOLIC HEART FAILURE | |
UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE | |
428.9 | HEART FAILURE UNSPECIFIED |
429.2 | CARDIOVASCULAR DISEASE UNSPECIFIED |
FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY - RUPTURE OF PAPILLARY MUSCLE | |
OTHER DISORDERS OF PAPILLARY MUSCLE - TAKOTSUBO SYNDROME | |
429.89 | OTHER ILL-DEFINED HEART DISEASES |
780.2 | SYNCOPE AND COLLAPSE |
786.02 | ORTHOPNEA |
786.05 | SHORTNESS OF BREATH |
786.09 | RESPIRATORY ABNORMALITY OTHER |
UNSPECIFIED CHEST PAIN - PRECORDIAL PAIN | |
786.59 | OTHER CHEST PAIN |
793.91 | IMAGE TEST INCONCLUSIVE DUE TO EXCESS BODY FAT |
793.99 | OTHER NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATIONS OF BODY STRUCTURE |
794.31 | NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) |
996.72 | OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT |
996.83 | COMPLICATIONS OF TRANSPLANTED HEART |
V42.1 | HEART REPLACED BY TRANSPLANT |
POSTSURGICAL AORTOCORONARY BYPASS STATUS - PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS | |
V58.11 | ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY |
V67.00 | FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY |
V72.81 | PRE-OPERATIVE CARDIOVASCULAR EXAMINATION |
The following diagnoses support the medical necessity of limited area PET imaging (78811 through 78816):
|
290.0 | SENILE DEMENTIA UNCOMPLICATED |
PRESENILE DEMENTIA UNCOMPLICATED - PRESENILE DEMENTIA WITH DEPRESSIVE FEATURES | |
SENILE DEMENTIA WITH DELUSIONAL FEATURES - SENILE DEMENTIA WITH DEPRESSIVE FEATURES | |
290.3 | SENILE DEMENTIA WITH DELIRIUM |
331.0 | ALZHEIMER'S DISEASE |
331.11 | PICK'S DISEASE |
331.19 | OTHER FRONTOTEMPORAL DEMENTIA |
331.2 | SENILE DEGENERATION OF BRAIN |
331.9 | CEREBRAL DEGENERATION UNSPECIFIED |
345.01 | GENERALIZED NONCONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY |
345.11 | GENERALIZED CONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY |
PETIT MAL STATUS EPILEPTIC - GRAND MAL STATUS EPILEPTIC | |
345.41 | LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH COMPLEX PARTIAL SEIZURES, WITH INTRACTABLE EPILEPSY |
345.51 | LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH SIMPLE PARTIAL SEIZURES, WITH INTRACTABLE EPILEPSY |
345.61 | INFANTILE SPASMS WITH INTRACTABLE EPILEPSY |
345.71 | EPILEPSIA PARTIALIS CONTINUA WITH INTRACTABLE EPILEPSY |
345.81 | OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITH INTRACTABLE EPILEPSY |
345.91 | EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY |
780.39 | OTHER CONVULSIONS |
780.93 | MEMORY LOSS |
Coverage Topic
Diagnostic Tests and X-Rays
Coding Information
CPT/HCPCS Codes
See above.
General Information
Other Comments
The following documentation must be maintained in the medical record to support the medical necessity of an FDG-PET scan for dementia and neurodegenerative diseases:
- Date of onset of symptoms
- Diagnosis of clinical syndrome
- Mini mental status exam (MMSE) or similar test score
- Presumptive cause (possible, probable, uncertain AD)
- Any neuropsychological testing performed
- Results of any structural imaging (MRI, CT) performed
- Relevant laboratory tests (B12, thyroid hormone)
- Number and name of prescribed medications
The following documentation must be maintained in the medical record to support the medical necessity of an FDG-PET scan for newly diagnosed and locally advanced cervical cancer:
- Pathological diagnosis of cervical cancer made before the FDG PET scan is performed
- The negative results of other imaging procedures (e.g., MRI or CT) for extra-pelvic metastasis
PET scans are covered only when performed at a PET imaging center with a PET scanner that has been approved or cleared by the FDA. When a claim is submitted, the provider is certifying this and must be able to produce a copy of this approval upon request. An official approval letter need not be submitted with the claim.
Revision History
Revision History Number
A47551
Revision History Explanation
| Date | Article # | Description |
|---|---|---|
08/01/2008 |
A47551 |
Article effective 08/01/2008 for DC Part A, Maryland Part A, and Pennsylvania Part A. Article is now effective for DC Part A and DCMA Part B; Maryland Part A and Maryland Part B; Pennsylvania Part A; and Delaware Part B. |
05/23/2008 |
A47551 |
Article to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |