Corporate

February 15, 2013 - Revised: 10.24.14

Coverage and Claim Submission for Positron Emission Tomography (PET) Scans

CGS has received numerous questions on the reporting of covered ICD-9-CM diagnosis codes for PET scans performed for oncologic conditions. CMS published the covered indications for PET scans in the National Coverage Determination Manual (Pub. 100-03), chapter 1, section 220.6.17 for the coverage of PET scans for the initial staging and subsequent staging of solid tumors and myeloma.

Effective for dates of service on and after June 11, 2013, CMS revised the NCD Manual to allow coverage of three PET scans when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same diagnosis. Coverage of any additional PET scans (beyond three) will be reviewed on a case-by-case basis by CGS.

Example: Each different cancer diagnosis is allowed one initial treatment strategy PET scan (with HCPCS modifier PI) and three subsequent treatment strategy PET scans (with HCPCS modifier PS). PET scans for subsequent treatment strategy (with HCPCS modifier PS) for the same cancer diagnosis (number four or more) require HCPCS modifier KX.

Note: A beneficiary’s file may or may not contain a claim for initial treatment strategy (with HCPCS modifier PI). The existence or non-existence of an initial strategy claim has no bearing on the frequency count of the subsequent treatment strategy claims (with HCPCS modifier PS).

Please use the appropriate CPT code when submitting claims for PET scans (appropriate modifier(s) also required):

  • 78608 – Brain imaging, Positron emission tomography (PET); metabolic evaluation
  • 78811 – Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
  • 78812 – Positron emission tomography (PET) imaging; skull base to mid-thigh
  • 78813 – Positron emission tomography (PET) imaging; whole body
  • 78814 – Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
  • 78815 – Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh
  • 78816 – Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
  • HCPCS modifier PI: PET to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
  • HCPCS modifier PS: PET to inform of the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that a PET study is needed to inform subsequent anti-tumor strategy

For claims approved for Coverage under Evidence Development (CED), HCPCS modifier Q0 (zero) (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) is also required.

Effective for claims with dates of service on and after June 11, 2013, the chart below summarizes national FDG PET coverage for oncologic conditions.  Some of the dx codes that were covered previously will no longer be covered.  Specifically, some of the Vxx.x diagnoses codes to indicate “History of cancer” are now non-covered.

CMS Change Request (CR) 8739External PDF

FDG PET for Cancers
Tumor Type

Initial Treatment Strategy
(formerly “diagnosis” & “staging”)

Subsequent Treatment Strategy (formerly “restaging” & “monitoring response to treatment”)

Colorectal

Cover

Cover

Esophagus

Cover

Cover

Head and Neck (not thyroid, CNS)

Cover

Cover

Lymphoma

Cover

Cover

Non-small cell lung

Cover

Cover

Ovary

Cover

Cover

Brain

Cover

Cover

Cervix

Cover with exceptions*

Cover

Small cell lung

Cover

Cover

Soft tissue sarcoma

Cover

Cover

Pancreas

Cover

Cover

Testes

Cover

Cover

Prostate

Non-cover

Cover

Thyroid

Cover

Cover

Breast (male and female)

Cover with exceptions*

Cover

Melanoma

Cover with exceptions*

Cover

All other solid tumors

Cover

Cover

Myeloma

Cover

Cover

All other cancers not listed

Cover

Cover

*Cervix: Nationally non-covered for the initial diagnosis of cervical cancer related to initial anti-tumor treatment strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are nationally covered.

*Breast: Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. Nationally covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for breast cancer are nationally covered.

*Melanoma: Nationally non-covered for initial staging of regional lymph nodes. All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.

Reference:


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