(Medicare Claims Processing Manual)

Payment for CPT codes 78890 and 78891 is bundled into payments for the primary procedure.   60 - Positron Emission Tomography (PET) Scans   General Information  (Rev. 1833; Issued:  10- 16-09; Effective Date:  04 -03-09; Implementation Date:  10- 30-09)  Positron emission tomography (PET) is a noninvasive imaging procedure that assesses perfusion and the level of metabolic activity in various organ systems of the human body. A positron camera (tomograph) is used to produce cross -sectional tomographic image s which are obtained by detecting radioactivity from a radioactive tracer substance (radiopharmaceutical) that emits a radioactive tracer substance (radiopharmaceutical FDG) such as 2 [F -18] flouro -D-glucose FDG, that is administered intravenously to the patient.   The Medicare National Coverage Determinations (NCD) Manual, chapter 1, 220.6, contains additional coverage instructions to indicate the conditions under which a PET scan is performed.   A.   Definitions   For all uses of PET, excluding Rubidium 82 for perfusion of the heart, myocardial viability and refractory seizures, the following definitions apply:    Diagnosis : PET is covered only in clinical situations in which the PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure .  In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning.  PET scans following a tissue diagnosis are generally performed for the purpose of staging, rather than diagnosis.  Therefore, the use of PET in the diagnosis of lymphoma, esophageal and colorectal cancers, as well as in melanoma, should be rare.  PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific signs and symptoms of disease).    Staging: PET is covered in clinical situations in which (1) (a) the stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound) or, (b) the use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patien t and, (2) clinical management of the patient would differ depending on the stage of the cancer identified.   NOTE:  Effective for services on or after April 3, 2009, the terms diagnosis and staging will be replaced with Initial Treatment Strategy.  For further information on this new term, refer to Pub. 100-03, NCD Manual, section 220.6.17.   Restaging:  PET will be covered for restaging: (1) after the completion of treatment for the purpose of detecting residual disease, (2) for detecting suspected recurrence, or metastasis, (3) to determine the extent of a known recurrence, or (4) if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is to determine the extent of a known recurrence, or i f study information is insufficient for the clinical management of the patient.  R estaging applies to testing after a course of treatment is completed and is covered subject to the conditions above.    Monitoring : Use of PET to monitor tumor response to treatment during the planned course of therapy (i.e., when a change in therapy is anticipated).  NOTE: Effective for services on or after April 3, 2009, the terms restaging and monitoring will be replaced with Subsequent Treatment Strategy.  For further information on this new term, refer to Pub. 100-03, NCD Manual, section 220.6.17.  B.  Limitations   For staging and restaging: PET is covered in either/or both of the following circumstances:    The stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound); and/or    The clinical management of the patient would differ depending on the stage of the cancer identified.  PET will be covered for restaging after the completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence, or to determine the extent of a known recurrence.  Use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient.   The PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific symptoms).  Use of PET to monitor tumor response during the planned course of therapy (i.e., when no change in therapy is being contemplated) is not covered.   60.1 - Billing Instructions  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014  Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  A.  Billing and Payment Instructions or Responsibilities for A/B MACs (B)   Claims for PET scan services must be billed using the ASC X12 837 professional claim format or on Form -CMS 1500 with the appropriate HCPCS or CPT code and diagnosis codes to the A/B MAC (B).  Effective for claims received on or after July 1, 2001, PET modifiers were discontinued and are no longer a claims processing requirement for PET scan claims.   Therefore, July 1, 2001, and after the MSN messages regarding the use of PET modifiers can be discontinued.  The type of service (TOS) for the new PET scan procedure codes is TOS 4, Diagnostic Radiology.  Payment is based on the Medicare Physician Fee Schedule.   B.  Billing and Payment Instructions or Responsibilities for A/B MACs (A)   Claims for PET scan procedures must be billed to the A/B MAC (A) on the ASC X12 837 institutional claim format or on Form CMS -1450 with the appropriate diagnosis and HCPCS G code or CPT code to indicate the conditions under which a PET scan was done.  These codes represent the technical component costs associated with these procedures when furnished to hospital and SNF outpatients. They are paid as follows:    under OPPS for hospitals subject to OPPS   under current payment methodologies for hospitals not subject to OPPS   on a reasonable cost basis for critical access hospitals.   on a reasonable cost basis for skilled nursing facilities.  Institutional providers bill these codes under Revenue Code 0404 (PET Scan).  Medicare contractors shall pay claims submitted for services provided by a critical access hospital (CAH) as follows: Method I technical services are paid at 101% of reasonable cost; Method II technical services are paid at 101% of reasonable cost, and pro fessional services are paid at 115% of the Medicare Physician Fee Schedule Data Base.   C.  Frequency   In the absence of national frequency limitations, for all indications covered on and after July 1, 2001, contractors can, if necessary, develop frequency limitations on any or all covered PET scan services.   D.  Post -Payment Review for PET Scans   As with any claim, but particularly in view of the limitations on this coverage, Medicare may decide to conduct post -payment reviews to determine that the use of PET scans is consistent with coverage instructions.  Pet scanning facilities must keep patient  record information on file for each Medicare patient for whom a PET scan claim is made.  These medical records can be used in any post -payment reviews and must include the information necessary to substantiate the need for the PET scan.  These records mus t include standard information (e.g., age, sex, and height) along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.  Such information must include, but is not limited to, the date, place and results of previous diagnostic tests (e.g., cytopathology and surgical pathology reports, CT), as well as the results and reports of the PET scan(s) performed at the center.  If available, such records should include the prognosis derived from the PET scan, together with information regarding the physician or institution to which the patient proceeded following the scan for treatment or evaluation.  The ordering physician is responsible for forwarding appropriate clinical data to the PET scan faci lity.  Effective for claims received on or after July 1, 2001, CMS no longer requires paper documentation to be submitted up front with PET scan claims. Contractors shall be aware and advise providers of the specific documentation requirements for PET scans for dementia and neurodegenerative diseases.  This information is outlined in section 60.12.  Documentation requirements such as physician referral and medical necessity determination are to be maintained by the provider as part of the beneficiarys medical record.  This information must be made available to the A/B MAC (A or B) upon request of additional documentation to determine appropriate payment of an individual claim.  60.2 - Use of Gamma Cameras and Full Ring and Partial Ring PET Scanners for PET Scans  (Rev. 527, Issued: 04- 15-05, Effective: 01 -28-05, Implementation: 04- 18-05)  See the Medicare NCD Manual, Section 220.6, concerning 2- [F-18] Fluoro- D-Glucose (FDG) PET scanners and details about coverage.   On July 1, 2001, HCPCS codes G0210 -  G0230 were added to allow billing for all currently covered indications for FDG PET.  Although the codes do not indicate the type of PET scanner, these codes were used until January 1, 2002, by providers to bill for ser vices in a manner consistent with the coverage policy.  Effective January 1, 2002, HCPCS codes G0210  G0230 were updated with new descriptors to properly reflect the type of PET scanner used.  In addition, four new HCPCS codes became effective for dates of service on and after January 1, 2002, (G0231, G0232, G 0233, G0234) for covered conditions that may be billed if a gamma camera is used for the PET scan.  For services performed from January 1, 2002, through January 27, 2005, providers should bill using the revised HCPCS codes G0210 -  G0234.  Beginning January 28, 2005 providers should bill using the appropriate CPT code.   60.2.1 - Coverage for Myocardial Viability  (Rev. 1, 10- 01-03) AB-02-065  The FDG PET is covered for the determination of myocardial viability following an inconclusive single photon computed tomography test (SPECT) from July 1, 2001, through September 30, 2002.  Only full ring scanners are covered as the scanning medium for this service from July 1, 2001, through December 31, 2001.  However, as of January 1, 2002, full a nd partial ring scanners are covered for myocardial viability following an inconclusive SPECT.   Beginning October 1, 2002, Medicare will cover FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, and will continue to cover FDG PET when used as a follow -up to an inconclusive SPECT.  However, if a patient received a FDG PET study with inconclusive results, a follow -up SPECT is not covered.  FDA full and partial ring PET scanners are covered.   In the event that a patient receives a SPECT with inconclusive results, a PET scan may be performed and covered by Medicare.  However, a SPECT is not covered following a FDG PET with inconclusive results.  See the Medicare National Coverage Determinations Manual for specific frequency limitations for Myocardial Viability following an inconclusive SPECT.  In the absence of national frequency limitations, contractors can, if necessary develop reasonable frequency limitations for myocardial viability.   Documentation that these conditions are met should be maintained by the referring physician as part of the beneficiarys medical record.   60.3 - PET Scan Qualifying Conditions and HCPCS Code Chart  (Rev. 527, Issued: 04- 15-05, Effective: 01 -28-05, Implementation: 04- 18-05)  Below is a summary of all covered PET scan conditions, with effective dates.