This article describes the least restrictive coverage possible. Providers must read the entire NCD and related Internet Only Manual (IOM) sections (see “Sources” at end of this article) in order to correctly understand and apply the following coding guidance. In some cases, depending on the clinical scenario, the same diagnosis code describes a condition that may be covered, covered with evidence development only, both, or non-covered. In these situations, the code will appear as covered, the least restrictive coverage possible under any circumstances, in this article.
PET Scan Procedure
Positron Emission Tomography (PET) is a minimally invasive diagnostic imaging procedure used to evaluate metabolism in normal tissue as well as in diseased tissues in conditions such as cancer, ischemic heart disease, and some neurologic disorders. A radiopharmaceutical is injected into the patient that gives off sub-atomic particles, known as positrons, as it decays. PET uses a positron camera (tomograph) to measure the decay of the radiopharmaceutical. The rate of decay provides biochemical information on the metabolism of the tissue being studied.
Indications and Limitations of Coverage
1. The following sections cover the codes used to describe PET scans and the diagnoses that may justify use of the scan if all other Medicare requirements for coverage are met. Details of Medicare coverage requirements are NOT quoted in this article. Providers should familiarize themselves with the NCD (IOM Medicare National Coverage Determination (NCD) Manual, Publication 100-03, Chapter 1, Part 4, Section 220.6.1, 220.6.8, 220.6.9, 220.6.13, 220.6.17, 220.6.19 and 220.6.20) on PET Scans, which is the source of all information in this article.
Unless otherwise indicated, the clinical conditions below are covered when PET utilizes FDG as a tracer.
2. Any use and all uses of PET scans that are not specifically listed in the NCDs listed above may be covered per local MAC discretion. Providers are encouraged to review the entire CMS NCD for PET Scans at: Medicare National Coverage Determination Manual, Chapter 1, Part 4 on the CMS Web site for further details and clarification of coverage. Providers are to bill G0235 for non-covered indications.
3. When PET Scans are performed in conjunction with a CMS-approved clinical trial or for an indication reimbursed under “Coverage with Evidence Development” (CED), providers must append the Q0 or Q1 modifier to the appropriate CPT code.
Q0 (Q zero) Investigational clinical trial service provided in a clinical research study that is in an approved clinical research study.
Q1 (Q one) Routine clinical Service provided in a clinical research study that is in an approved clinical research study.
Institutional claims must also include diagnosis code Z00.6 and condition code 30 to denote clinical trial.
4. Claims for FDG PET or imaging for oncologic indications for initial treatment strategy must include the “PI” modifier. Claims for FDG PET imaging for oncologic indications for subsequent strategy must include the “PS” modifier.
PI – 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.
PS – PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy.
CPT/HCPCS Providers are expected to select the procedure code appropriate to the diagnosis of the clinical condition documented in the patient records.
Sources:
Internet Only Manual (IOM) Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 4, Section 220.6
IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 13, Section 60.3
Technical Direction Letter (TDL)-13390, 06-26-2013
CMS Change Request (CR) 8381, 08-02-2013
Effective for dates of service on or after December 15, 2017, coverage under CED of NaF-18 PET to identify bone metastasis of cancer reverts to a national non-coverage decision.