Corporate

July 10, 2014

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.

Note: Effective for services performed on and after June 11, 2013, the CED requirement ended and HCPCS modifier Q0 is no longer required.

The chart below lists covered indications for PET scans, by ICD-9-CM code, for dates of service January 1, 2013, through June 10, 2013.

A list of appropriate diagnosis codes for dates of service on and after June 11, 2013, can be found in Attachment A of CMS Change Request (CR) 8739External PDF.

Submitted with HCPCS modifier PI Submitted with HCPCS modifiers PI and Q0* *HCPCS modifier Q0 is no longer required for services performed on and after June 11, 2013. Submitted with HCPCS modifier PS Submitted with HCPCS modifiers PS and Q0* *HCPCS modifier Q0 is no longer required for services performed on and after June 11, 2013.
V10.03 183.8-183.9 V10.11 V10.03 V10.11
V10.05-V10.06 184.0-184.9 V10.21 V10.05-V10.6 V10.21-V10.22
V10.22 186.0 172.9 V10.3 V10.71-V10.72
V10.3 186.9 198.5 140.0-140.9 V10.82
V10.71-V10.72 1871.-187.9 202.40-202.48 141.0-141.6 151.0-151.9
V10.82 188.0-188.9 203.80-203.82 141.8-141.9 152.0-152.9
140.0-140.9 189.0-189.9 204.00-204.02 142.0-142.2 154.0-154.8
140.0-141.6 190.0-190.9 204.10-204.12 142.8-142.9 155.0-155.2
141.8-141.9 191.0-191.9 204.20-204.22 143.0-143.1 156.0-156.9
142.0-142.2 192.0-192.9 204.80-204.82 143.8-143.9 157.0-157.4
142.8-142.9 193 204.90-204.92 144.0-144.1 157.8-157.9
143.0-143.1 194.0-194.9 205.00-205.02 144.8-144.9 158.0-158.9
143.8-143.9 195.0-195.8 205.10-205.12 145.0-145.6 159.0-159.9
144.0-144.1 196.1 205.20-205.22 145.8-145.9 161.0-161.9
144.8-144.9 199.0-199.2 205.30-205.32 146.0-146.4 162.0-162.9
145.0-145.6 200.00-200.88 205.80-205.82 146.6-146.9 163.0-163.9
145.8-145.9 201.00-201.98 205.90-205.92 147.0-147.3 164.0-164.9
146.0-146.9 202.00-202.28 206.00-206.02 147.8-147.9 165.0-165.9
147.0-147.3 202.50-202.68 206.10-206.12 148.0-148.3 170.0-170.9
147.8-147.9 202.70-202.78 206.20-206.22 148.8-148.9 171.0-171.9
148.0-148.3 202.80-202.88 206.80-206.82 149.0-149.1 173.0-173.9
148.8-148.9 202.90-202.98 206.90-206.92 149.8-149.9 176.0-176.5
149.0-149.1 203.00-203.12 207.00-207.02 150.0-150.9 176.8-176.9
149.8-149.8 209.00-209.36 207.10-207.12 153.0-153.9 179
150.0-150.9 203.00-203.12 207.20-207.22 154.0-154.8 181
151.0-151.9 209.00-209.36 207.80-207.82 160.0-160.9 182.0-182.8
152.0-152.9 209.70-209.79 208.00-208.02 162.0-162.9 184.0-184.9
153.0-153.9 235.1 208.10-208.12 163.0-163.9 186.0-186.9
154.0-154.8 239.1 208.20 164.0-164.9 187.1-187.9
155.0-155.2 518.89 208.80-208.82 172.0-172.9 188.0-188.9
156.0-156.9 793.1 208.90-208.92 174.0-175.9 189.0-189.9
157.0-157.4 793.11-793.19 235.2 180.0-180.9 190.0-190.9
157.8-157.9   235.5-235.7 183.0 191.0-191.9
158.0-158.9   235.9 183.2-183.5 192.0-192.9
159.0-159.9   236.0 183.8-183.9 194.0-194.9
160.0-160.9   238.6 185 195.1-195.8
161.0-161.9     193 202.40-202.48
162.0-162.9     195.0 203.80-203.82
163.0-163.9     196.0-196.9 204.00-204.92
164.0-164.9     197.0-197.8 205.00-205.92
165.0-165.9     198.0-198.89 206.00-206.92
170.0-170.9     199.0-199.2 207.00-207.82
171.0-171.9     200.00-200.88 208.00-208.92
172.0-172.9     201.00-201.98 209.00-209.36
173.00-173.99     202.00-202.28 209.70-209.79
174.0-175.9     202.50-202.68 235.0
176.0-176.5     202.70-202.78 235.2
176.8-176.9     202.80-202.88 235.5-235.7
179     202.90-202.98 235.9
180.0-180.9     203.00-203.12 238.6
181     235.1  
182.0-182.8     239.1  
183.0     793.1  
183.2-183.5     793.11-793.19  

Reference:


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