Contractor Information
Contractor Name:
Highmark Medicare Services, Inc.
Contractor Number:
12102, 12202, 12302, 12501, 12301, 12201, 12401
Contractor Type:
MAC Part A & B
Article Information
Article ID Number
A47551
Article Type
Article
Key Article
No
Article Title
National Coding Determination (NCD) Article for Positron Emission Tomography (PET) Scans
Primary Geographic Jurisdiction
Pennsylvania, Maryland, District of Columbia, NEW JERSEY, DELAWARE
Original Article Effective Date
07/11/2008
Article Revision Effective Date
09/25/2008
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) |
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ICD-9 Codes that Support Medical Necessity
Medicare is establishing the following limited coverage for CPT/HCPCS codes 78459, 78491, and 78492:
Please see Revision History for codes effective 10/01/2008.
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 |
414.3 |
CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE |
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 |
|
V45.87 |
TRANSPLANTED ORGAN REMOVAL STATUS |
V45.88 |
STATUS POST ADMINISTRATION OF TPA (RTPA) IN A DIFFERENT FACILITY WITHIN THE LAST 24 HOURS PRIOR TO ADMISSION TO CURRENT FACILITY |
V58.11 |
ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY |
V67.00 |
FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY |
V72.81 |
PRE-OPERATIVE CARDIOVASCULAR EXAMINATION |
|
|
MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER |
|
MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT - MALIGNANT NEOPLASM OF COMMISSURE OF LIP |
|
MALIGNANT NEOPLASM OF OTHER SITES OF LIP - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER |
|
MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF LINGUAL TONSIL |
|
MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED |
|
MALIGNANT NEOPLASM OF PAROTID GLAND - MALIGNANT NEOPLASM OF SUBLINGUAL GLAND |
|
MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS - MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED |
|
MALIGNANT NEOPLASM OF UPPER GUM - MALIGNANT NEOPLASM OF LOWER GUM |
|
MALIGNANT NEOPLASM OF OTHER SITES OF GUM - MALIGNANT NEOPLASM OF GUM UNSPECIFIED |
|
MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH |
|
MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED |
|
MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF RETROMOLAR AREA |
|
MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH - MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED |
|
MALIGNANT NEOPLASM OF TONSIL - MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE |
|
MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX - MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX |
|
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX - MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE |
|
MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL |
|
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE |
|
MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED - MALIGNANT NEOPLASM OF WALDEYER'S RING |
|
MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY |
|
MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS |
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MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE |
|
151.0 |
MALIGNANT NEOPLASM OF CARDIA |
MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE |
|
MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE |
|
154.8 |
MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS |
MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF SPHENOIDAL SINUS |
|
MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES - MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED |
|
MALIGNANT NEOPLASM OF GLOTTIS - MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES |
|
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED |
|
162.0 |
MALIGNANT NEOPLASM OF TRACHEA |
MALIGNANT NEOPLASM OF MAIN BRONCHUS - MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG |
|
MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED |
|
170.0 |
MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE |
170.1 |
MALIGNANT NEOPLASM OF MANDIBLE |
171.0 |
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK |
MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED |
|
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE |
|
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST |
|
MALIGNANT NEOPLASM OF ENDOCERVIX - MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE |
|
MALIGNANT NEOPLASM OF VAGINA - MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED |
|
187.1 |
MALIGNANT NEOPLASM OF PREPUCE |
187.4 |
MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED |
187.7 |
MALIGNANT NEOPLASM OF SCROTUM |
187.9 |
MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED |
MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED |
|
193 |
MALIGNANT NEOPLASM OF THYROID GLAND |
195.0 |
MALIGNANT NEOPLASM OF HEAD FACE AND NECK |
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK - SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES SITE UNSPECIFIED |
|
SECONDARY MALIGNANT NEOPLASM OF LUNG - SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS AND SPLEEN |
|
SECONDARY MALIGNANT NEOPLASM OF KIDNEY - SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS |
|
SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD - SECONDARY MALIGNANT NEOPLASM OF ADRENAL GLAND |
|
SECONDARY MALIGNANT NEOPLASM OF BREAST - SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS |
|
198.89 |
SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES |
DISSEMINATED MALIGNANT NEOPLASM - MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN |
|
RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S SARCOMA UNSPECIFIED SITE - HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE - HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE - HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES |
|
CARCINOMA IN SITU OF LIP ORAL CAVITY AND PHARYNX - CARCINOMA IN SITU OF ANUS UNSPECIFIED |
|
CARCINOMA IN SITU OF LARYNX - CARCINOMA IN SITU OF OTHER SPECIFIED PARTS OF RESPIRATORY SYSTEM |
|
518.89 |
OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED |
793.1 |
NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD |
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TONGUE - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS |
|
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM RECTOSIGMOID JUNCTION AND ANUS |
|
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRONCHUS AND LUNG - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TRACHEA |
|
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARYNX - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF NASAL CAVITIES MIDDLE EAR AND ACCESSORY SINUSES |
|
V10.3 |
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST |
V10.41 |
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF CERVIX UTERI |
PERSONAL HISTORY OF LYMPHOSARCOMA AND RETICULOSARCOMA - PERSONAL HISTORY OF OTHER LYMPHATIC AND HEMATOPOIETIC NEOPLASMS |
|
V10.82 |
PERSONAL HISTORY OF MALIGNANT MELANOMA OF SKIN |
V10.87 |
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF THYROID |
V71.1 |
OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM |
The following diagnoses support the medical necessity of brain PET for metabolic evaluation (78608):
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.
Other 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 Explanation
| Date | Article # | Description |
|---|---|---|
09/24/2008 |
A47551 |
The following ICD-9 code changes will be effective 10/01/2008 due to ICD-9-CM annual updates. New codes added to cardiac – related PET (CPT codes 78459, 78491, 78492): 414.3, V45.87, and V45.88. New code added to cancer - related PET (CPT codes 78811-78816): 199.2. Some of these changes are within a code range. Article revision effective 09/25/2008. |
08/29/2008 |
A47551 |
Article effective 09/01/2008 for New Jersey Part A. Effective 09/01/2008, New Jersey Part A will be added to the other jurisdictions already effective: DC Part A and DCMA Part B; Maryland Part A and Maryland Part B; Pennsylvania Part A; and Delaware Part B. |
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. |