Positron Emission Tomography (PET) is a non-invasive imaging procedure used to assess metabolic activity and perfusion in various organ systems in the human body. Images are obtained from positron-emitting radioisotopes that are usually administered intravenously. 2-[F18] fluoro-2-deoxy-D-glucose (FDG) is most often used as the radioisotope tracer in PET imaging procedures for cardiac (i.e., myocardial viability), neuropsychiatric and oncologic evaluations. In addition, myocardial perfusion imaging of the heart utilizes N-13 and Rb-82 tracers. Therefore, designation of these different tracers will be identified within each of the four separate sets of medical necessity criteria.
PET scanning differs from its anatomic-based imaging counterparts (e.g., Computed Tomography (CT)) by generating functional images of pathophysiologic activity. Please note that CT scanners are now being combined with PET scanners. This dual technology poses several advantages such as shorter imaging times and the automatic co registration of CT (anatomic) and PET (metabolic) information.
Per Pub. 100-03, Chapter 1, Part 4, Section 220.6, numerous clinical indications have been approved for imaging via a National Coverage Determination (NCD). CMS revised NCD 220.6 effective October 30, 2009, for services performed on or after Apri1 3, 2009, on patients with known or suspected cancer. The revised national coverage provides four categories of coverage for two categories of cancer management. The coverage categories are: covered (without exception), covered with exception, covered with evidence development, and non-covered. The two categories of cancer management are: Initial Treatment Strategy and Subsequent Treatment Strategy.
Per Pub. 100-03, Chapter 1, Part 4, Section 220.6.19 (Change Request 6861), effective July 6, 2010, for services performed on or after February 26, 2010, PET imaging performed with NaF-18 to inform initial or subsequent treatment strategy is covered for known or suspected metastatic cancer to bone for patients enrolled in (and providers participating in) a prospective clinical study as outlined in Pub. 100-03, Section 220.6.
This LCD contains several sets of covered ICD-9-CM diagnosis codes for use in automated claim review. The first sets apply to all PET imaging services performed prior to April 3, 2009. The subsequent sets apply to PET imaging services performed on or after April 3, 2009, on patients with known or suspected cancer and PET imaging services with NaF performed on or after February 26, 2010.
Because of the complexity of the NCD’s coverage and required coding, providers of PET imaging services must review the NCD and code their claims appropriately and accordingly.
Please note that some non-covered indications of PET may be in areas of nuclear medicine testing where dedicated PET CPT codes have not traditionally been used (e.g., bone scans). In such instances, G0235, as described in the Related Article Coding Guidelines, must be used.
Limitations:
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
0404
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and CMS require the use of short CPT descriptors in policies published on the Web.
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78459©
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Heart muscle imaging (pet)
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78491©
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Heart image (pet), single
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78492©
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Heart image (pet), multiple
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78608©
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Brain imaging (pet)
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78811©
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Tumor imaging (pet), limited
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78812©
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Tumor image (pet)/skull-thigh
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78813©
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Tumor image (pet) full body
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78814©
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Tumor image pet/ct, limited
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78815©
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Tumor image pet/ct skull-thigh
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78816©
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Tumor image pet/ct full body
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A9526*
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Nitrogen N-13 ammonia
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A9552*
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F18 fdg
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A9555*
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Rb82 rubidium
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A9580*
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NaF-18
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*Note: HCPCS codes of the radiopharmaceutical tracer must be billed on the same claim as the PET imaging CPT code.
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
For PET imaging services for non-cancer-related conditions
Medicare is establishing the following limited coverage for CPT/HCPCS codes A9552 and 78459:
Covered for:
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402.00–402.01
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Malignant hypertensive heart disease without/with heart failure
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410.00–410.02 begin_of_the_skype_highlighting 00–410.02 end_of_the_skype_highlighting
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Acute myocardial infarction of anterolateral wall
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410.10–410.12
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Acute myocardial infarction of other anterior wall
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410.20–410.22
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Acute myocardial infarction of inferolateral wall
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410.30–410.32
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Acute myocardial infarction of inferoposterior wall
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410.40–410.42
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Acute myocardial infarction of other inferior wall
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410.50–410.52
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Acute myocardial infarction of other lateral wall
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410.60–410.62
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True posterior wall infarction
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410.70–410.72
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Subendocardial infarction
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410.80–410.82
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Acute myocardial infarction of other specified sites
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410.90–410.92
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Acute myocardial infarction, unspecified site
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411.0–411.1
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Other acute and subacute forms of ischemic heart disease
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411.81
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Acute coronary occlusion without myocardial infarction
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411.89
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Other acute and subacute forms of Ischemic heart disease other
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412
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Old myocardial infarction
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413.0–413.1
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Angina pectoris
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413.9
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Other and unspecified angina pectoris
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414.00–414.03 begin_of_the_skype_highlighting 00–414.03 end_of_the_skype_highlighting
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Coronary atherosclerosis
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414.10
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Aneurysm of heart (wall)
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414.3
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Coronary atherosclerosis due to lipid rich plaque
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414.8
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Other specified forms of chronic ischemic heart disease
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425.0–425.5
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Cardiomyopathy
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425.7–425.9
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Cardiomyopathy
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428.0–428.1
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Heart failure
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428.20–428.23
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Systolic heart failure
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428.30–428.33
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Diastolic heart failure
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428.40–428.43
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Combined systolic and diastolic heart failure
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428.9
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Heart failure, unspecified
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793.91
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Image test inconclusive due to excess body fat
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793.99
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Other nonspecific (abnormal) findings on radiological and other examination of body structure
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V70.7*
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Examination of participant in clinical trial
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Note: V70.7* is used on claims for participants registered in CMS-approved clinical trial. Part A only
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Medicare is establishing the following limited coverage for CPT/HCPCS codes A9526, A9555, 78491 and 78492:
Covered for:
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410.00–410.02 begin_of_the_skype_highlighting 00–410.02 end_of_the_skype_highlighting
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Acute myocardial infarction of anterolateral wall
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410.10–410.12
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Acute myocardial infarction of other anterior wall
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410.20–410.22
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Acute myocardial infarction of inferolateral wall
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410.30–410.32
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Acute myocardial infarction of inferoposterior wall
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410.40–410.42
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Acute myocardial infarction of other inferior wall
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410.50–410.52
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Acute myocardial infarction of other lateral wall
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410.60–410.62
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True posterior wall infarction
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410.70–410.72
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Subendocardial infarction
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410.80–410.82
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Acute myocardial infarction of other specified sites
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410.90–410.92
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Acute myocardial infarction, unspecified site
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411.0–411.1
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Other acute and subacute forms of ischemic heart disease
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411.81
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Acute coronary occlusion without myocardial infarction
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411.89
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Other acute and subacute forms of ischemic heart disease
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412
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Old myocardial infarction
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413.0–413.1
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Angina pectoris
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413.9
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Other and unspecified angina pectoris
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414.00–414.07 begin_of_the_skype_highlighting 00–414.07 end_of_the_skype_highlighting
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Coronary atherosclerosis
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414.10–414.12
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Aneurysm and dissection of heart
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414.19
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Other aneurysm of heart
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414.3
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Coronary atherosclerosis due to lipid rich plaque
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414.8–414.9
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Other forms of chronic ischemic heart disease
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427.0–427.2
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Cardiac dysrhythmias
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427.41–427.42
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Ventricular fibrillation and flutter
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427.5
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Cardiac Arrest
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428.0–428.1
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Heart failure
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428.20–428.23
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Systolic heart failure
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428.30–428.33
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Diastolic heart failure
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428.40–428.43
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Combined systolic and diastolic heart failure
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429.4–429.6
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Ill-defined descriptions and complications of heart disease
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429.81–429.83
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Other ill-defined heart diseases
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429.89
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Other ill-defined heart diseases
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786.02
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Symptoms involving respiratory system and other chest symptoms, orthopnea
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786.05
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Shortness of breath
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786.09
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Other dyspnea & respiratory abnormalities (respiratory distress)
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786.50–786.51
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Chest pain
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786.59
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Other chest pain
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793.91
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Image test inconclusive due to excess body fat
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793.99
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Other nonspecific (abnormal) findings on radiological and other examination of body structure
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794.31
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Abnormal electrocardiogram
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996.72
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Other complications due to other cardiac device implant and graft
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996.83
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Complications of transplanted heart
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V42.1
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Heart replaced by transplant
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V45.81–V45.82
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Other post-procedural status
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V58.11
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Encounter for antineoplastic chemotherapy
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V72.81*
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Pre-operative cardiovascular examination
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Note: See the “Indications and Limitations of Coverage and/or Medical Necessity” section in this policy as well as “Coding Guidelines” in the related article regarding appropriate billing for preoperative studies.
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Medicare is establishing the following limited coverage for CPT/HCPCS codes A9552 and 78608 for differential diagnosis of Alzheimer’s versus frontotemporal dementia:
Covered for:
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290.0
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Senile dementia, uncomplicated
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290.10–290.13
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Presenile dementia
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290.20–290.21
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Senile dementia with delusional or depressive features
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290.3
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Senile dementia with delirium
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331.0
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Other cerebral degenerations, Alzheimer’s disease
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331.11
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Other cerebral degenerations, frontotemporal dementia, Pick’s disease
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331.19
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Other cerebral degenerations, other frontotemporal dementia
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331.2
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Other cerebral degenerations, senile degeneration of brain
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331.9
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Cerebral degeneration, unspecified
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345.01
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Generalized nonconvulsive epilepsy, with intractable epilepsy
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345.11
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Generalized convulsive epilepsy, with intractable epilepsy
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345.2–345.3
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Epilepsy and recurrent seizures
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345.41
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Partial epilepsy, with impairment of consciousness, with intractable epilepsy
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345.51
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Partial epilepsy, without mention of impairment of consciousness, with intractable epilepsy
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345.61
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Infantile spasms, with intractable epilepsy
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345.71
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Epilepsia partialis continua, with intractable epilepsy
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345.81
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Other forms of epilepsy, with intractable epilepsy
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345.91
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Epilepsy, unspecified, with intractable epilepsy
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780.39
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General symptoms, other convulsions
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780.93
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General symptoms, memory loss
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V70.7*
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Examination of participant in clinical trial
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Note: V70.7* is used on claims for participants registered in CMS-approved clinical trial. Part A only
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For PET imaging services performed prior to April 3, 2009, on patients with known or suspected cancer
Medicare is establishing the following limited coverage for CPT/HCPCS codes A9552, 78811, 78812, 78813, 78814, 78815 and 78816:
Covered for:
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140.0–140.1
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Malignant neoplasm of lip
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140.3–140.6
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Malignant neoplasm of lip
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140.8–140.9
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Malignant neoplasm of lip
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141.0–141.6
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Malignant neoplasm of tongue
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141.8–141.9
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Malignant neoplasm of tongue
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142.0–142.2
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Malignant neoplasm of major salivary glands
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142.8–142.9
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Malignant neoplasm of major salivary glands
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143.0–143.1
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Malignant neoplasm of gum
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143.8–143.9
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Malignant neoplasm of gum
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144.0–144.1
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Malignant neoplasm of floor of mouth
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144.8–144.9
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Malignant neoplasm of floor of mouth
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145.0–145.6
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Malignant neoplasm of other and unspecified parts of mouth
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145.8–145.9
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Malignant neoplasm of other and unspecified parts of mouth
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146.0–146.9
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Malignant neoplasm of oropharynx
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147.0–147.3
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Malignant neoplasm of nasopharynx
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147.8–147.9
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Malignant neoplasm of nasopharynx
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148.0–148.3
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Malignant neoplasm of hypopharynx
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148.8–148.9
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Malignant neoplasm of hypopharynx
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149.0–149.1
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Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
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149.8–149.9
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Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
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150.0–150.5
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Malignant neoplasm of esophagus
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150.8–150.9
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Malignant neoplasm of esophagus
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153.0–153.9
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Malignant neoplasm of colon
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154.0–154.3
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Malignant neoplasm of rectum, rectosigmoid junction and anus
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154.8
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Other malignant neoplasm of rectum, rectosigmoid junction and anus
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160.0–160.5
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Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
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160.8–160.9
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Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
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161.0–161.3
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Malignant neoplasm of larynx
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161.8–161.9
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Malignant neoplasm of larynx
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162.0
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Malignant neoplasm of trachea
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162.2–162.5
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Malignant neoplasm of trachea, bronchus and lung
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162.8–162.9
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Malignant neoplasm of trachea, bronchus and lung
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170.0–170.1
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Malignant neoplasm of bone and articular cartilage
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171.0
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Malignant neoplasm of connective and other soft tissue of head, face, and neck
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172.0–172.9
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Malignant melanoma of skin
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174.0–174.6
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Malignant neoplasm of female breast
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174.8–174.9
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Malignant neoplasm of female breast
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175.0
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Malignant neoplasm of male breast, nipple and areola
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175.9
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Malignant neoplasm of other and unspecified sites of male breast
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180.0–180.1
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Malignant neoplasm of cervix uteri
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180.8–180.9
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Malignant neoplasm of cervix uteri
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184.0–184.4
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Malignant neoplasm of other and unspecified sites of female genital organs
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184.8–184.9
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Malignant neoplasm of other specified/unspecified sites of female genital organs
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187.1
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Malignant neoplasm of prepuce
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187.4
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Malignant neoplasm of penis, part unspecified
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187.7
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Malignant neoplasm of scrotum
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187.9
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Malignant neoplasm of male genital organ, site unspecified
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190.0–190.3
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Malignant neoplasm of eye
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190.5–190.9
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Malignant neoplasm of eye
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193
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Malignant neoplasm of thyroid gland
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195.0
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Malignant neoplasm of head, face, and neck
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200.00–200.08
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Reticulosarcoma
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200.10–200.18
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Lymphosarcoma
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200.20–200.28
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Burkitt’s tumor or lymphoma
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200.30–200.38
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Marginal zone lymphoma
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200.40–200.48
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Mantle cell lymphoma
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200.50–200.58
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Primary central nervous system lymphoma
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200.60–200.68
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Anaplastic large cell lymphoma
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200.70–200.78
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Large cell lymphoma
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200.80–200.88
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Other named variants of lymphosarcoma and reticulosarcoma
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201.00–201.08
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Hodgkin’s paragranuloma
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201.10–201.18
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Hodgkin’s granuloma
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201.20–201.28
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Hodgkin’s sarcoma
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201.40–201.48
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Lymphocytic-histiocytic predominance
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201.50–201.58
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Hodgkin’s disease, nodular sclerosis
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201.60–201.68
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Hodgkin’s disease, mixed cellularity
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201.70–201.78
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Hodgkin’s disease, lymphocytic depletion
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201.90–201.98
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Hodgkin’s disease, unspecified
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202.00–202.08
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Nodular lymphoma
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202.10–202.18
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Mycosis fungoides
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202.20–202.28
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Sezary’s disease
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202.30–202.38
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Malignant histiocytosis
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202.40–202.48
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Leukemic reticuloendotheliosis
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202.50–202.58
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Letterer-Siwe disease
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202.60–202.68
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Malignant mast cell tumors
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202.70–202.78
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Peripheral T cell lymphoma
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202.80–202.88
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Other malignant lymphomas
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202.90–202.98
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Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue
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518.7
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Transfusion related acute lung injury (TRALI)
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518.89
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Other diseases of lung, not elsewhere classified
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793.1
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Nonspecific abnormal findings on radiological and other examination of lung field
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793.91
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Image test inconclusive due to excess body fat
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793.99
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Other nonspecific (abnormal) findings on radiological and other examination of body structure
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V10.3
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Personal history of malignant neoplasm, breast
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V10.82*
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Personal history of malignant melanoma of skin
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Note: Use V10.82 when PET is used in restaging of malignant melanoma of skin.
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V70.7*
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Examination of participant in clinical trial
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Note: V70.7* is used on claims for participants registered in CMS-approved clinical trial. Part A only
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V71.1*
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Observation for suspected malignant neoplasm, not found
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Note: V71.1* should be used in reference to the metastatic evaluation of those primary neoplasms covered in the NCD (Pub. 100-04, Chapter 1, Part 4, Section 220.6).
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PET imaging services performed on or after April 3, 2009, on patients with known or suspected cancer –Initial Treatment Strategy
PET imaging (CPT codes 78608, 78811, 78812, 78813, 78814, 78815 and 78816) performed on or after April 3, 2009, for determination of initial treatment strategy for suspected or biopsy-proven solid tumors must be reported with modifier PI.
Per CMS NCD, Medicare is establishing the following limited coverage for determination of initial treatment strategy forCPT/HCPCS codes A9552, 78608, 78811, 78812, 78813, 78814, 78815 and 78816:
Covered for:
Table A
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140.0–140.1
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Malignant neoplasm of lip
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140.3–140.6
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Malignant neoplasm of lip
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140.8–140.9
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Malignant neoplasm of lip
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141.0–141.6
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Malignant neoplasm of tongue
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|
141.8–141.9
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Malignant neoplasm of tongue
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142.0–142.2
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Malignant neoplasm of major salivary glands
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142.8–142.9
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Malignant neoplasm of major salivary glands
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143.0–143.1
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Malignant neoplasm of gum
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|
143.8–143.9
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Malignant neoplasm of gum
|
|
144.0–144.1
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Malignant neoplasm of floor of mouth
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|
144.8–144.9
|
Malignant neoplasm of floor of mouth
|
|
145.0–145.6
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Malignant neoplasm of other and unspecified parts of mouth
|
|
145.8–145.9
|
Malignant neoplasm of other and unspecified parts of mouth
|
|
146.0–146.9
|
Malignant neoplasm of oropharynx
|
|
147.0–147.3
|
Malignant neoplasm of nasopharynx
|
|
147.8–147.9
|
Malignant neoplasm of nasopharynx
|
|
148.0–148.3
|
Malignant neoplasm of hypopharynx
|
|
148.8–148.9
|
Malignant neoplasm of hypopharynx
|
|
149.0–149.1
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
|
149.8–149.9
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
|
150.0–150.5
|
Malignant neoplasm of esophagus
|
|
150.8–150.9
|
Malignant neoplasm of esophagus
|
|
151.0–151.6
|
Malignant neoplasm of stomach
|
|
151.8–151.9
|
Malignant neoplasm of stomach
|
|
152.0–152.3
|
Malignant neoplasm of small intestine, including duodenum
|
|
152.8–152.9
|
Malignant neoplasm of small intestine, including duodenum
|
|
153.0–153.9
|
Malignant neoplasm of colon
|
|
154.0–154.3
|
Malignant neoplasm of rectum, rectosigmoid junction, and anus
|
|
154.8
|
Malignant neoplasm of rectum, rectosigmoid junction, and anus
|
|
155.0–155.2
|
Malignant neoplasm of liver and intrahepatic bile ducts
|
|
156.0–156.2
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
|
156.8–156.9
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
|
157.0–157.4
|
Malignant neoplasm of pancreas
|
|
157.8–157.9
|
Malignant neoplasm of pancreas
|
|
158.0
|
Malignant neoplasm of retroperitoneum
|
|
158.8–158.9
|
Malignant neoplasm of peritoneum
|
|
159.0–159.1
|
Malignant neoplasm of other and ill-defined sites within digestive tract and peritoneum
|
|
159.8–159.9
|
Malignant neoplasm of other and ill-defined sites within digestive tract and peritoneum
|
|
160.0–160.5
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
|
160.8–160.9
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
|
161.0–161.3
|
Malignant neoplasm of larynx
|
|
161.8–161.9
|
Malignant neoplasm of larynx
|
|
162.0
|
Malignant neoplasm of trachea
|
|
162.2–162.5
|
Malignant neoplasm of trachea, bronchus and lung
|
|
162.8–162.9
|
Malignant neoplasm of trachea, bronchus and lung
|
|
163.0–163.1
|
Malignant neoplasm of pleura
|
|
163.8–163.9
|
Malignant neoplasm of pleura
|
|
164.0–164.3
|
Malignant neoplasm of thymus, heart, and mediastinum
|
|
164.8–164.9
|
Malignant neoplasm of thymus, heart, and mediastinum
|
|
165.0
|
Malignant neoplasm of other and ill-defined sites within respiratory system and intrathoracic organs
|
|
165.8–165.9
|
Malignant neoplasm of other and ill-defined sites within respiratory system and intrathoracic organs
|
|
170.0–170.9
|
Malignant neoplasm of bone and articular cartilage
|
|
171.0
|
Malignant neoplasm of connective and other soft tissue
|
|
171.2–171.9
|
Malignant neoplasm of connective and other soft tissue
|
|
172.0–172.9***
|
Malignant melanoma of skin
|
|
173.0–173.9
|
Other malignant neoplasm of skin
|
|
174.0–174.6***
|
Malignant neoplasm of female breast
|
|
174.8–174.9***
|
Malignant neoplasm of female breast
|
|
175.0***
|
Malignant neoplasm of male breast, nipple and areola
|
|
175.9***
|
Malignant neoplasm of other and unspecified sites of male breast
|
|
176.0–176.5
|
Kaposi’s sarcoma
|
|
176.8–176.9
|
Kaposi’s sarcoma
|
|
179
|
Malignant neoplasm of uterus, part unspecified
|
|
180.0–180.1***
|
Malignant neoplasm of cervix uteri
|
|
180.8–180.9***
|
Malignant neoplasm of cervix uteri
|
|
181
|
Malignant neoplasm of placenta
|
|
182.0–182.1
|
Malignant neoplasm of body of uterus
|
|
182.8
|
Malignant neoplasm of body of uterus
|
|
183.0
|
Malignant neoplasm of ovary
|
|
183.2–183.5
|
Malignant neoplasm of fallopian tube and uterine adnexa
|
|
183.8–183.9
|
Malignant neoplasm of uterine adnexa
|
|
184.0–184.4
|
Malignant neoplasm of other and unspecified sites of female genital organs
|
|
184.8–184.9
|
Malignant neoplasm of other specified/unspecified sites of female genital organs
|
|
186.0
|
Malignant neoplasm of testis
|
|
186.9
|
Malignant neoplasm of testis
|
|
187.1–187.9
|
Malignant neoplasm of penis and other male genital organs
|
|
188.0–188.9
|
Malignant neoplasm of bladder
|
|
189.0–189.4
|
Malignant neoplasm of kidney, ureter, urethra, and paraurethral glands
|
|
189.8–189.9
|
Malignant neoplasm of other and unspecified urinary organs
|
|
190.0–190.9
|
Malignant neoplasm of eye
|
|
191.0–191.9
|
Malignant neoplasm of brain
|
|
192.0–192.3
|
Malignant neoplasm of other and unspecified parts of nervous system
|
|
192.8–192.9
|
Malignant neoplasm of other and unspecified parts of nervous system
|
|
193
|
Malignant neoplasm of thyroid gland
|
|
194.0–194.1
|
Malignant neoplasm adrenal gland and parathyroid gland
|
|
194.3–194.6
|
Malignant neoplasm of other endocrine organs and related structures
|
|
194.8–194.9
|
Malignant neoplasm of other and unspecified endocrine organs and related structures
|
|
195.0–195.5***
|
Malignant neoplasm of other and ill defined sites
|
|
195.8***
|
Malignant neoplasm of other and ill defined sites
|
|
196.0–196.3***
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
196.5–196.6***
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
196.8–196.9***
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
197.0–197.8***
|
Secondary malignant neoplasm of respiratory and digestive systems
|
|
198.0–198.7***
|
Secondary malignant neoplasm of other specified sites
|
|
198.81–198.82***
|
Secondary malignant neoplasm of other specified sites
|
|
198.89***
|
Secondary malignant neoplasm of other specified sites
|
|
199.0–199.2***
|
Malignant neoplasm without specification of site
|
|
200.00–200.08
|
Reticulosarcoma
|
|
200.10–200.18
|
Lymphosarcoma
|
|
200.20–200.28
|
Burkitt’s tumor or lymphoma
|
|
200.30–200.38
|
Marginal zone lymphoma
|
|
200.40–200.48
|
Mantle cell lymphoma
|
|
200.50–200.58
|
Primary central nervous system lymphoma
|
|
200.60–200.68
|
Anaplastic large cell lymphoma
|
|
200.70–200.78
|
Large cell lymphoma
|
|
200.80–200.88
|
Other named variants of lymphosarcoma and reticulosarcoma
|
|
201.00–201.08
|
Hodgkin’s paragranuloma
|
|
201.10–201.18
|
Hodgkin’s granuloma
|
|
201.20–201.28
|
Hodgkin’s sarcoma
|
|
201.40–201.48
|
Lymphocytic-histiocytic predominance
|
|
201.50–201.58
|
Hodgkin’s disease, nodular sclerosis
|
|
201.60–201.68
|
Hodgkin’s disease, mixed cellularity
|
|
201.70–201.78
|
Hodgkin’s disease, lymphocytic depletion
|
|
201.90–201.98
|
Hodgkin’s disease, unspecified
|
|
202.00–202.08
|
Nodular lymphoma
|
|
202.10–202.18
|
Mycosis fungoides
|
|
202.20–202.28
|
Sezary’s disease
|
|
202.30–202.38
|
Malignant histiocytosis
|
|
202.40–202.48
|
Leukemic reticuloendotheliosis
|
|
202.50–202.58
|
Letterer-Siwe Disease
|
|
202.60–202.68
|
Malignant mast cell tumors
|
|
202.70–202.78
|
Peripheral T cell lymphoma
|
|
202.80–202.88
|
Other malignant lymphomas
|
|
202.90–202.98
|
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue
|
|
203.00–203.02
|
Multiple myeloma
|
|
203.10–203.12
|
Plasma cell leukemia
|
|
203.80–203.82
|
Other immunoproliferative neoplasms
|
|
204.00–204.02*
|
Acute Lymphoid leukemia
|
|
204.10–204.12*
|
Chronic lymphoid leukemia
|
|
204.20–204.22*
|
Subacute lymphoid leukemia
|
|
204.80–204.82*
|
Other lymphoid leukemia
|
|
204.90–204.92*
|
Unspecified lymphoid leukemia
|
|
205.00–205.02*
|
Acute Myeloid leukemia
|
|
205.10–205.12*
|
Chronic myeloid leukemia
|
|
205.20–205.22*
|
Subacute myeloid leukemia
|
|
205.30–205.32*
|
Myeloid sarcoma
|
|
205.80–205.82*
|
Other myeloid leukemia
|
|
205.90–205.92*
|
Unspecified myeloid leukemia
|
|
206.00–206.02*
|
Acute monocytic leukemia
|
|
206.10–206.12*
|
Chronic monocytic leukemia
|
|
206.20–206.22*
|
Subacute monocytic leukemia
|
|
206.80–206.82*
|
Other monocytic leukemia
|
|
206.90–206.92*
|
Unspecified monocytic leukemia
|
|
207.00–207.02*
|
Acute erythremia and erythroleukemia
|
|
207.10–207.12*
|
Chronic erythremia
|
|
207.20–207.22*
|
Megakaryocytic leukemia
|
|
207.80–207.82*
|
Other specified leukemia
|
|
208.00–208.02*
|
Acute leukemia of unspecified cell type
|
|
208.10–208.12*
|
Chronic leukemia of unspecified cell type
|
|
208.20–208.22*
|
Subacute leukemia of unspecified cell type
|
|
208.80–208.82*
|
Other leukemia of unspecified cell type
|
|
208.90–208.92*
|
Unspecified leukemia
|
|
209.00–209.03
|
Malignant carcinoid tumors of the small intestine
|
|
209.10–209.17
|
Malignant carcinoid tumors of the appendix, large intestine, and rectum
|
|
209.20–209.27
|
Malignant carcinoid tumors of other and unspecified sites
|
|
209.29
|
Malignant carcinoid tumors of other sites
|
|
209.30–209.36
|
Malignant poorly differentiated neuroendocrine tumors
|
|
235.0–235.9***
|
Neoplasm of uncertain behavior of digestive and respiratory system
|
|
236.0–236.7***
|
Neoplasm of uncertain behavior of genitourinary organs
|
|
236.90–236.91***
|
Neoplasm of uncertain behavior of genitourinary organs
|
|
236.99***
|
Neoplasm of uncertain behavior of genitourinary organs
|
|
237.0–237.6***
|
Neoplasm of uncertain behavior of endocrine glands and nervous system
|
|
237.9***
|
Neoplasm of uncertain behavior of endocrine glands and nervous system
|
|
238.0–238.3***
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
238.5–238.6***
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
238.8–238.9***
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
793.0–793.7***
|
Other nonspecific (abnormal) findings on radiological and other examination of body structure
|
|
793.91***
|
Image test inconclusive due to excess body fat
|
|
V71.1***
|
Observation for suspected malignant neoplasm, not found
|
PET imaging services performed on or after April 3, 2009, on patients with known cancer – Subsequent Treatment Strategy
PET imaging (CPT codes 78608, 78811, 78812, 78813, 78814, 78815 and 78816) performed for determination of subsequent treatment strategy for patients with known cancer must be reported with modifier PS.
Per CMS NCD, Medicare is establishing the following limited coverage for determination of subsequent treatment strategy for CPT/HCPCS codes A9552, 78608, 78811, 78812, 78813, 78814, 78815 and 78816:
Covered for:
Table B
|
140.0–140.1
|
Malignant neoplasm of lip
|
|
140.3–140.6
|
Malignant neoplasm of lip
|
|
140.8–140.9
|
Malignant neoplasm of lip
|
|
141.0–141.6
|
Malignant neoplasm of tongue
|
|
141.8–141.9
|
Malignant neoplasm of tongue
|
|
142.0–142.2
|
Malignant neoplasm of major salivary glands
|
|
142.8–142.9
|
Malignant neoplasm of major salivary glands
|
|
143.0–143.1
|
Malignant neoplasm of gum
|
|
143.8–143.9
|
Malignant neoplasm of gum
|
|
144.0–144.1
|
Malignant neoplasm of floor of mouth
|
|
144.8–144.9
|
Malignant neoplasm of floor of mouth
|
|
145.0–145.6
|
Malignant neoplasm of other and unspecified parts of mouth
|
|
145.8–145.9
|
Malignant neoplasm of other and unspecified parts of mouth
|
|
146.0–146.9
|
Malignant neoplasm of oropharynx
|
|
147.0–147.3
|
Malignant neoplasm of nasopharynx
|
|
147.8–147.9
|
Malignant neoplasm of nasopharynx
|
|
148.0–148.3
|
Malignant neoplasm of hypopharynx
|
|
148.8–148.9
|
Malignant neoplasm of hypopharynx
|
|
149.0–149.1
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
|
149.8–149.9
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
|
150.0–150.5
|
Malignant neoplasm of esophagus
|
|
150.8–150.9
|
Malignant neoplasm of esophagus
|
|
151.0–151.6*
|
Malignant neoplasm of stomach
|
|
151.8–151.9*
|
Malignant neoplasm of stomach
|
|
152.0–152.3*
|
Malignant neoplasm of small intestine
|
|
152.8–152.9*
|
Malignant neoplasm of small intestine
|
|
153.0–153.9
|
Malignant neoplasm of colon
|
|
154.0–154.3
|
Malignant neoplasm of rectum, rectosigmoid, and anus
|
|
154.8
|
Malignant neoplasm of rectum, rectosigmoid, and anus
|
|
155.0–155.2*
|
Malignant neoplasm of liver and intrahepatic bile ducts
|
|
156.0–156.2*
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
|
156.8–156.9*
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
|
157.0–157.4*
|
Malignant neoplasm of pancreas
|
|
157.8–157.9*
|
Malignant neoplasm of pancreas
|
|
158.0*
|
Malignant neoplasm of retroperitoneum
|
|
158.8–158.9*
|
Malignant neoplasm of peritoneum
|
|
159.0–159.1*
|
Malignant neoplasm of other and ill-defined sites within digestive tract and peritoneum
|
|
159.8–159.9*
|
Malignant neoplasm of other and ill-defined sites within digestive tract and peritoneum
|
|
160.0–160.5
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
|
160.8–160.9
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
|
161.0–161.3
|
Malignant neoplasm of larynx
|
|
161.8–161.9
|
Malignant neoplasm of larynx
|
|
162.0**
|
Malignant neoplasm of trachea
|
|
162.2–162.5**
|
Malignant neoplasm of trachea, bronchus and lung
|
|
162.8–162.9**
|
Malignant neoplasm of trachea, bronchus and lung
|
|
163.0–163.1*
|
Malignant neoplasm of pleura
|
|
163.8–163.9*
|
Malignant neoplasm of pleura
|
|
164.0–164.3*
|
Malignant neoplasm of thymus, heart, and mediastinum
|
|
164.8–164.9*
|
Malignant neoplasm of thymus, heart, and mediastinum
|
|
165.0*
|
Malignant neoplasm of other and ill-defined sites within respiratory system and intrathoracic organs
|
|
165.8–165.9*
|
Malignant neoplasm of other and ill-defined sites within respiratory system and intrathoracic organs
|
|
170.0–170.1*
|
Malignant neoplasm of bone and articular cartilage
|
|
170.2–170.9*
|
Malignant neoplasm of bone and articular cartilage
|
|
171.0*
|
Malignant neoplasm of connective and other soft tissue
|
|
171.2–171.9*
|
Malignant neoplasm of connective and other soft tissue
|
|
172.0–172.9
|
Malignant melanoma of skin
|
|
173.0–173.4*
|
Other malignant neoplasm of skin
|
|
173.5–173.9*
|
Other malignant neoplasm of skin
|
|
174.0–174.6
|
Malignant neoplasm of female breast
|
|
174.8–174.9
|
Malignant neoplasm of female breast
|
|
175.0
|
Malignant neoplasm of male breast, nipple and areola
|
|
175.9
|
Malignant neoplasm of other and unspecified sites of male breast
|
|
176.0–176.1*
|
Kaposi’s sarcoma
|
|
176.2*
|
Kaposi’s sarcoma, palate
|
|
176.3–176.5*
|
Kaposi’s sarcoma
|
|
176.8–176.9*
|
Kaposi’s sarcoma
|
|
179*
|
Malignant neoplasm of uterus, part unspecified
|
|
180.0–180.1
|
Malignant neoplasm of cervix uteri
|
|
180.8–180.9
|
Malignant neoplasm of cervix uteri
|
|
181*
|
Malignant neoplasm of placenta
|
|
182.0–182.1*
|
Malignant neoplasm of body of uterus
|
|
182.8*
|
Malignant neoplasm of body of uterus
|
|
183.0
|
Malignant neoplasm of ovary
|
|
183.2–183.5*
|
Malignant neoplasm of fallopian tube and uterine adnexa
|
|
183.8–183.9*
|
Malignant neoplasm of uterine adnexa
|
|
184.0–184.4*
|
Malignant neoplasm of other and unspecified sites of female genital organs
|
|
184.8–184.9*
|
Malignant neoplasm of other specified/unspecified sites of female genital organs
|
|
185*
|
Malignant neoplasm of prostate
|
|
186.0*
|
Malignant neoplasm of testis
|
|
186.9*
|
Malignant neoplasm of testis
|
|
187.1–187.9*
|
Malignant neoplasm of penis and other male genital organs
|
|
188.0–188.9*
|
Malignant neoplasm of bladder
|
|
189.0–189.4*
|
Malignant neoplasm of kidney, ureter, urethra, and paraurethral glands
|
|
189.8–189.9*
|
Malignant neoplasm of other and unspecified urinary organs
|
|
190.0–190.9*
|
Malignant neoplasm of eye
|
|
191.0–191.9*
|
Malignant neoplasm of brain
|
|
192.0–192.3*
|
Malignant neoplasm of other and unspecified parts of nervous system
|
|
192.8–192.9*
|
Malignant neoplasm of other and unspecified parts of nervous system
|
|
193***
|
Malignant neoplasm of thyroid gland
|
|
194.0*
|
Malignant neoplasm of adrenal gland
|
|
194.1*
|
Malignant neoplasm of parathyroid gland
|
|
194.3–194.4*
|
Malignant neoplasm of other endocrine organs and related structures
|
|
194.5
|
Malignant neoplasm of other endocrine organs and related structures
|
|
194.6*
|
Malignant neoplasm of other endocrine organs and related structures
|
|
194.8–194.9*
|
Malignant neoplasm of other endocrine organs and related structures
|
|
195.0
|
Malignant neoplasm of other and ill defined sites
|
|
195.1–195.8***
|
Malignant neoplasm of other and ill defined sites
|
|
196.0–196.3***
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
196.5–196.6***
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
196.8–196.9***
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
197.0–197.8***
|
Secondary malignant neoplasm of respiratory and digestive systems
|
|
198.0–198.7***
|
Secondary malignant neoplasm of other specified sites
|
|
198.81–198.82***
|
Secondary malignant neoplasm of other specified sites
|
|
198.89***
|
Secondary malignant neoplasm of other specified sites
|
|
199.0–199.2***
|
Malignant neoplasm without specification of site
|
|
200.00–200.08
|
Reticulosarcoma
|
|
200.10–200.18
|
Lymphosarcoma
|
|
200.20–200.28
|
Burkitt’s tumor or lymphoma
|
|
200.30–200.38
|
Marginal zone lymphoma
|
|
200.40–200.48
|
Mantle cell lymphoma
|
|
200.50–200.58
|
Primary central nervous system lymphoma
|
|
200.60–200.68
|
Anaplastic large cell lymphoma
|
|
200.70–200.78
|
Large cell lymphoma
|
|
200.80–200.88
|
Other named variants of lymphosarcoma and reticulosarcoma
|
|
201.00–201.08
|
Hodgkin’s paragranuloma
|
|
201.10–201.18
|
Hodgkin’s granuloma
|
|
201.20–201.28
|
Hodgkin’s sarcoma
|
|
201.40–201.48
|
Lymphocytic-histiocytic predominance
|
|
201.50–201.58
|
Hodgkin’s disease, nodular sclerosis
|
|
201.60–201.68
|
Hodgkin’s disease, mixed cellularity
|
|
201.70–201.78
|
Hodgkin’s disease, lymphocytic depletion
|
|
201.90–201.98
|
Hodgkin’s disease, unspecified
|
|
202.00–202.08
|
Nodular lymphoma
|
|
202.10–202.18
|
Mycosis fungoides
|
|
202.20–202.28
|
Sezary’s disease
|
|
202.30–202.38
|
Malignant histiocytosis
|
|
202.40–202.48
|
Leukemic reticuloendotheliosis
|
|
202.50–202.58
|
Letterer-Siwe Disease
|
|
202.60–202.68
|
Malignant mast cell tumors
|
|
202.70–202.78
|
Peripheral T cell lymphoma
|
|
202.80–202.88
|
Other malignant lymphomas
|
|
202.90–202.98
|
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue
|
|
203.00–203.02
|
Multiple myeloma
|
|
203.10–203.12
|
Plasma cell leukemia
|
|
203.80–203.82
|
Other immunoproliferative neoplasms
|
|
204.00–204.02*
|
Acute Lymphoid leukemia
|
|
204.10–204.12*
|
Chronic lymphoid leukemia
|
|
204.20–204.22*
|
Subacute lymphoid leukemia
|
|
204.80–204.82*
|
Other lymphoid leukemia
|
|
204.90–204.92*
|
Unspecified lymphoid leukemia
|
|
205.00–205.02*
|
Acute Myeloid leukemia
|
|
205.10–205.12*
|
Chronic myeloid leukemia
|
|
205.20–205.22*
|
Subacute myeloid leukemia
|
|
205.30–205.32*
|
Myeloid sarcoma
|
|
205.80–205.82*
|
Other myeloid leukemia
|
|
205.90–205.92*
|
Unspecified myeloid leukemia
|
|
206.00–206.02*
|
Acute Monocytic leukemia
|
|
206.10–206.12*
|
Chronic monocytic leukemia
|
|
206.20–206.22*
|
Subacute monocytic leukemia
|
|
206.80–206.82*
|
Other monocytic leukemia
|
|
206.90–206.92*
|
Unspecified monocytic leukemia
|
|
207.00–207.02*
|
Acute erythremia and erythroleukemia
|
|
207.10–207.12*
|
Chronic erythremia
|
|
207.20–207.22*
|
Megakaryocytic leukemia
|
|
207.80–207.82*
|
Other specified leukemia
|
|
208.00–208.02*
|
Acute leukemia of unspecified cell type
|
|
208.10–208.12*
|
Chronic leukemia of unspecified cell type
|
|
208.20–208.22*
|
Subacute leukemia of unspecified cell type
|
|
208.80–208.82*
|
Other leukemia of unspecified cell type
|
|
208.90–208.92*
|
Unspecified leukemia
|
|
209.00–209.03*
|
Malignant carcinoid tumors of the small intestine
|
|
209.10–209.17*
|
Malignant carcinoid tumors of the appendix, large intestine, and rectum
|
|
209.20–209.27*
|
Malignant carcinoid tumors of other and unspecified sites
|
|
209.29*
|
Malignant carcinoid tumors of other sites
|
|
209.30–209.32*
|
Malignant poorly differentiated neuroendocrine tumors
|
|
209.33–209.36*
|
Malignant poorly differentiated neuroendocrine tumors
|
|
235.0–235.9***
|
Neoplasm of uncertain behavior of digestive and respiratory system
|
|
236.0–236.7***
|
Neoplasm of uncertain behavior of genitourinary organs
|
|
236.90–236.91***
|
Neoplasm of uncertain behavior of genitourinary organs
|
|
236.99***
|
Neoplasm of uncertain behavior of genitourinary organs
|
|
237.0–237.6***
|
Neoplasm of uncertain behavior of endocrine glands and nervous system
|
|
237.9***
|
Neoplasm of uncertain behavior of endocrine glands and nervous system
|
|
238.0–238.2***
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
238.3***
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
238.5–238.6***
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
238.8–238.9***
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
V58.0***
|
Encounter for radiotherapy
|
|
V58.11***
|
Encounter for antineoplastic chemotherapy
|
|
V58.42***
|
Aftercare for neoplasm following surgery
|
|
V67.00***
|
Following surgery, unspecified
|
|
V67.1–V67.2***
|
Following radiotherapy and chemotherapy
|
*These diagnoses are covered only when provided in an approved clinical research study. Report these codes with the Q0 modifier to signify services provided in such a study.
**Subsequent treatment strategy PET imaging is covered only for non-small-cell tumors. Other lung cancers reported with these codes are covered only in an approved clinical research study and must be reported with the Q0 modifier.
*** For all diagnoses marked with three asterisks, providers must follow provisions of the NCD and only report for payment appropriate tumors and cancers as specified (i.e., report for payment those tumors covered under CED when performed according to NCD provisions and not reporting non-covered tumors). When reporting secondary tumors, follow NCD for coverage of PET imaging for primary tumor site when origin is known.
PET imaging services with NaF-18, performed on or after February 26, 2010, on patients with known or suspected metastatic cancer to bone – Initial Treatment Strategy (PI) and for patients with known metastatic cancer to bone – Subsequent Treatment Strategy (PS)
Per the CMS NCD, CPT/HCPCS codes A9580, 78811, 78812, 78813, 78814, 78815 and 78816 are covered for all diagnoses listed in the PI and PS covered diagnosis tables A and B above. Providers must follow provisions of the NCD and only report for payment appropriate tumors and cancers as specified by the NCD. These services are covered only when provided in an approved clinical research study. Report these codes with the Q0 modifier to signify services provided in such a study.
When reporting NaF PET imaging for metastatic bone cancer, modifiers PI or PS must also be appended to indicate initial or subsequent treatment strategy, respectively. Report modifier KX with all other required modifiers on claims for the professional component of PET imaging services (modifier 26 services) to indicate covered NaF-18 services for metastatic cancer to bone.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.