Corporate

October 24, 2013 - Revised 12.18.17

Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) Scans for Solitary Pulmonary Nodule

CMS continues to nationally cover one FDG PET studyfor beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary's treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for therapeutic purposes related to the initial anti-tumor treatment strategy.

The presence of a solitary pulmonary nodule is a covered indication for FDG PET scans, provided that certain criteria are met. Effective for services performed on or after October 1, 2013, CGS will cover one PET scan for solitary pulmonary nodule:

  • ONLY after other tests have been performed, and
  • The physician has continued suspicion that the nodule is cancerous AND needs the PET scan to guide subsequent testing/therapy

Submit claims as follows:

  • PET CT: use CPT code 78815, PET imaging with attenuation correction (acCT) and anatomical localization imaging; skull base to mid-thigh, AND
    • HCPCS modifier PI (Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing; short descriptor: PET tumor init tx strat), AND
    • The appropriate ICD-10 code
  • Non CT PET: use CPT code 78811, PET imaging limited area if performed without concurrent CT attenuation correction (acCT)
  • Reminder: medical records must be made available upon request and must clearly establish the medical necessity of this service.

Reference:


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