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LCD Reference Article Billing and Coding Article

Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions

A53134

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A53134
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
10/13/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Internet-Only Manuals (IOMs):

  • CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 4, Section 220.6.9 FDG PET for Refractory Seizures and Section 220.6.13 FDG Positron Emission Tomography (PET) for Dementia and Neurodegenerative Diseases
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 13, Section 60 Positron Emission Tomography (PET) Scans – General Information

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text


The CMS Medicare National Coverage Determinations (NCD) Manual, IOM Publication 100-03, Section 220.6, discusses Positron Emission Tomography (PET) Scans coverage. This Billing and Coding Article provides billing and coding guidance regarding the use of PET scans for several non-oncologic conditions.

Specifically, this article addresses the sections listed above in the CMS National Coverage Policy.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.

This contractor has listed specific ICD-10-CM diagnosis codes as eligible for coverage of PET non-oncologic claims. However, please note that the ICD-10-CM diagnosis code, as always, is only one piece of information in support of the medical necessity of the service. All requirements of the applicable NCD must be met, and the clinical documentation in the medical record must support that all of the requirements of the NCD have been met. Please see the applicable NCD section for specific information regarding the clinical documentation expected to be found in the medical record to support that all of the requirements of the NCD have been met.

This article describes the least restrictive coverage possible. Providers must read the entire applicable NCD and related documents in order to correctly understand and apply the following coding guidance. In some cases, depending on the clinical scenario, the same ICD-10-CM diagnosis code describes a condition that may be covered, covered with evidence development only, both, or non-covered.

Dementia is a good example here. While the ICD-10-CM diagnosis codes for various types of dementia appear in this article, an eligible diagnosis is only one of the elements required for coverage. NCD Section 220.6.13 for FDG PET for Dementia and Neurodegenerative Diseases has many other required elements for coverage, and they differ by indication. NCD Section 220.6.13.B.1 discusses all of the requirements for a FDG PET scan to be considered medically reasonable and necessary when used in patients who have recently been diagnosed with dementia (documented cognitive decline of at least 6 months), and who meet diagnostic criteria for both Alzheimer's disease (AD) and Fronto-temporal dementia (FTD). NCD Section 220.6.13.B.2 discusses all of the requirements for a FDG PET scan to be considered medically reasonable and necessary when used in patients with mild cognitive impairment (MCI) or early dementia in the context of a CMS-approved clinical trial. NCD Section 220.6.13.C basically states that all other uses of FDG PET for dementia remain non-covered.

Reporting Guidelines

  1. Professional and Technical Components
    • The procedure codes listed for PET scans represent the global service. Therefore, providers performing only the technical or professional component of the test should use modifier TC or 26, respectively.
  2. Clinical Trial
    • FDG PET scans performed in the context of a CMS-approved practical clinical trial utilizing a specific protocol to demonstrate the utility of FDG PET in the diagnosis and treatment of disease should be reported with the Q0 modifier (number "0", not letter "O".)
  3. PET and CT
    • If a PET scan is obtained and, on the same date of service, diagnostic CT scan(s) are obtained at a separate session, then both the PET scan and the CT scan(s) may be coded individually. If a PET/CT study is performed concurrently on a hybrid PET/CT scanner and an additional diagnostic CT scan is also obtained non-concurrently, it is appropriate to code the PET/CT scan and the diagnostic CT scan(s) separately (whether the diagnostic CT scans are performed on a hybrid PET/CT scanner or on a dedicated CT scanner). To further clarify, the CT component of a PET/CT scan is for concurrently obtained CT scans for attenuation correction and localization and does not include any additional diagnostic CT studies that may be requested.
    • When a diagnostic CT scan is performed concurrently with a PET scan, the appropriate PET scan and the appropriate diagnostic CT code may be reported. If a medically necessary diagnostic CT is performed non-concurrently with a PET/CT scan, either on the PET/CT scanner or on an independent CT scanner, the appropriate PET/CT procedure code and the diagnostic CT study(s) code may be reported.
  4. CPT code 78609 is a non-covered service.
  5. HCPCS code A4641 is not an applicable tracer for PET scans.
  6. PET Radiopharmaceutical/Tracer codes A9597 or A9598 should only be used when there is no existing dedicated PET tracer code available (reference Medicare Claims Processing Manual, Chapter 13, Section 60.3.2). Specifically, there are two circumstances that would warrant the use of A9597 or A9598 as follows: (1) After Food and Drug Administration (FDA) approval of a PET oncologic indication, or (2) after CMS approves coverage of a new PET indication, and ONLY if either of those situations requires the use of a dedicated PET radiopharmaceutical/tracer code that is currently non-existent. An appropriate PET CPT code must be on the claim when any PET radiopharmaceutical/tracer code is reported, along with any appropriate modifiers (e.g., Q0 as applicable).

Positron Emission Tomography Reference Table

CPT Tracer/Code Comment
78608 FDG/A9552 Covered indications: Alzheimer’s disease/dementias, only when used to differentiate between Alzheimer's Disease and Fronto-temporal dementia, intractable seizures only when used as part of a pre-surgical evaluation.
78609 Not Applicable Nationally non-covered


Note: This table is not a comprehensive listing of covered indications. Providers should refer to the applicable NCD sections for detailed information regarding covered indications for PET scans.

Other Comments

PET scans are covered only when performed at a PET imaging center with a PET scanner that has been approved or cleared by the FDA. When a claim is submitted, the provider is certifying this and must be able to produce a copy of this approval upon request. An official approval letter need not be submitted with the claim.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

(55 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following diagnoses support the medical necessity of brain FDG PET for non-oncologic condition metabolic evaluation (CPT code 78608) as per the specific indications and limitations of NCD 220.6.9 FDG PET for Refractory Seizures and the applicable sections of NCD 220.6.13 for FDG PET for Dementia and Neurogenerative Diseases.

 Group 1 Codes
Code Description
F03.90 Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.911 Unspecified dementia, unspecified severity, with agitation
F03.918 Unspecified dementia, unspecified severity, with other behavioral disturbance
F03.92 Unspecified dementia, unspecified severity, with psychotic disturbance
F03.93 Unspecified dementia, unspecified severity, with mood disturbance
F03.94 Unspecified dementia, unspecified severity, with anxiety
F03.A0 Unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.A11 Unspecified dementia, mild, with agitation
F03.A18 Unspecified dementia, mild, with other behavioral disturbance
F03.A2 Unspecified dementia, mild, with psychotic disturbance
F03.A3 Unspecified dementia, mild, with mood disturbance
F03.A4 Unspecified dementia, mild, with anxiety
F03.B0 Unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.B11 Unspecified dementia, moderate, with agitation
F03.B18 Unspecified dementia, moderate, with other behavioral disturbance
F03.B2 Unspecified dementia, moderate, with psychotic disturbance
F03.B3 Unspecified dementia, moderate, with mood disturbance
F03.B4 Unspecified dementia, moderate, with anxiety
F03.C0 Unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.C11 Unspecified dementia, severe, with agitation
F03.C18 Unspecified dementia, severe, with other behavioral disturbance
F03.C2 Unspecified dementia, severe, with psychotic disturbance
F03.C3 Unspecified dementia, severe, with mood disturbance
F03.C4 Unspecified dementia, severe, with anxiety
F05* Delirium due to known physiological condition
G30.9 Alzheimer's disease, unspecified
G31.01 Pick's disease
G31.09 Other frontotemporal neurocognitive disorder
G31.1 Senile degeneration of brain, not elsewhere classified
G31.9 Degenerative disease of nervous system, unspecified
G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus
G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.A11 Absence epileptic syndrome, intractable, with status epilepticus
G40.A19 Absence epileptic syndrome, intractable, without status epilepticus
G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus
G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.803 Other epilepsy, intractable, with status epilepticus
G40.804 Other epilepsy, intractable, without status epilepticus
G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.823 Epileptic spasms, intractable, with status epilepticus
G40.824 Epileptic spasms, intractable, without status epilepticus
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
R41.2 Retrograde amnesia
R41.3 Other amnesia
R56.9 Unspecified convulsions
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10 code F05 must be reported with ICD-10 code F03.90 (F03.90 is a standalone code).
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. 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 (IOM) Publication 100-04, Medicare Claims Processing Manual, for further guidance.
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Coding Table Information

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/13/2023 R16

Article revised and published on 11/30/2023 effective for dates of service on and after 10/13/2023. References to the CMS NCD 220.6.20 for Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease have been removed from the article.
10/01/2022 R15

Article revised and published on 10/20/2022 effective for dates of service on and after 10/01/2022 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been added to the article: F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4 in Group 1. For the following ICD-10-CM codes the code description has changed: F03.90, G31.09 in Group 1.
07/01/2022 R14

Article revised and published on 08/04/2022 effective for dates of service on and after 07/01/2022 to reflect the July quarterly CPT/HCPCS code updates. HCPCS code A9601 was added to the CPT/HCPCS Group 1.
04/25/2021 R13

Article revised and published on 03/24/2022. The ‘Article Text’ section and the 'PET Reference Table' were revised to remove the reference to the billing and coding article A53132, NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions as this article is being retired on 03/24/2022. The ‘Reporting Guidelines’ section has been revised for bullet #6 to remove reference to the PI and PS modifiers. The ‘ICD-10-CM Codes that Support Medical Necessity’ section for the ‘Group 1 Paragraph’ has been revised to add the reference to NCD 220.6.9 FDG PET for Refractory Seizures and to remove reference to the billing and coding article A53132. The ‘Asterisk Note’ for the ‘Group 1 Codes’ in this section has been revised to: *ICD-10 code F05 must be reported with ICD-10 code F03.90 (F03.90 is a standalone code). Minor formatting changes have been made throughout.
04/25/2021 R12

Article revised and published on 04/22/2021 effective for dates of service on and after 04/25/2021 to revise the ‘Internet-Only Manuals’ section to delete NCD references to Cardiac PET. The ‘Positron Emission Tomography Reference Table’ was revised to remove the rows for CPT codes 78459, 78491 and 78492. The ‘Group 1 Codes’ in the ‘CPT/HCPCS Codes’ section was revised to delete the following CPT/HCPCS codes: 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492, A9526, and A9555. The ‘ICD-10 Codes that Support Medical Necessity’ section was revised to delete the entire ‘Group 1 Paragraph’ and ‘Group 1 Codes’. Minor formatting changes have been made throughout the coding section.
01/01/2020 R11

Article revised and published on 04/09/2020 effective for dates of service on and after 01/01/2020. In response to CR 11655 and an update to the NCD, Current Procedural Terminology (CPT) codes 78429, 78430, 78431, 78432, 78433 and 78434 have been added to code group 1 and to the ICD-10 code group 1 paragraph. A reference to CR 11655 related to tracer A9598 was added to the reporting guidelines.
01/01/2020 R10

Article revised and published on 01/16/2020 effective for dates of service on and after 01/01/2020 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS code(s) have either a short description and/or a long description change. Depending on which description is used in this article, there may not be any change in how the code displays in the document: 78459, 78491 and 78492.
10/01/2019 R9

Article revised and published on 10/17/2019 effective for dates of service on and after 10/01/2019 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10 codes have been deleted and therefore have been removed from the article: I48.1 and I48.2. The following ICD-10-CM codes have been added to ICD-10 group 1 of the Article: I48.11, I48.19, I48.20 and I48.21. IOM and Change Request references have been moved from the Article Text to the CMS National Coverage section of the article. Asterisks have been added to ICD-10 codes Z94.1, Z94.3, Z95.1, and Z98.61 in the ICD-10 code group and the note pertaining to these codes has been moved to the asterisk explanation at the bottom of the table. An asterisk has been added to ICD-10 code F05 in the ICD-10 group 2 and the note pertaining to this code has been moved to the asterisk explanation at the bottom of the table. Please note: System changes have been made to our articles in response to CMS Change Request 10901. The Coding Section has been reordered and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.
10/01/2018 R8

Article revised and published on 10/25/2018 effective for dates of service on and after 10/01/2018 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been deleted and therefore removed from the Article: R93.8. The following ICD-10-CM code(s) have been added to the Article Group 1 codes: R93.89.

Per article review, removed the IOM reference (IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, Section 60.3.2) above the “Positron Emission Tomography Reference Table” as the IOM has been revised and no longer contains the table. The table was kept in the article for educational purposes.
01/01/2018 R7

Article revised and published on 01/25/2018. Effective for dates of service on and after 01/01/2018, per TN 3911, CR 10319, PET tracer codes A9597 or A9598 have been added to the Group 1 codes and “reporting guideline #6” has been added with coding information specific to these codes. The following CPT/HCPCS code(s) have been deleted per the annual HCPCS updates and per TN 1875, CR 10184, for NCD 220.6.20 and therefore have been removed from the article: A9599. Per annual review of this article, added header for “Reporting Guidelines” and added hyperlink to related article A53132 NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions to the “Associated Documents” section.
10/01/2017 R6

Article revised and published on 10/05/2017 effective for dates of service on and after 10/01/2017 to reflect the annual ICD-10-CM code updates.

The following ICD-10-CM codes have been added to the Article: Group 1 Code Additions: I21.9, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, and I50.89.

The following ICD-10-CM code has undergone a descriptor change: Group 1 Code Descriptor Revision: I50.1.

Additional revisions include: added references to relevant guidelines throughout the article and clarification on reporting PET Aβ imaging.
01/01/2017 R5 Article revised and published on 01/12/2017 effective for dates of service on and after 01/01/2017. Per TN 1708 CR 9751 for NCD 220.6.20 for Beta Amyloid Positron Tomography in Dementia and Neurodegenerative Disease, HCPCS codes Q9982 and Q9983 have been added to the Article text for use with PET Aß imaging through CED effective 07/01/2016.
10/01/2016 R4 Article revised and published on 09/29/2016 effective for dates of service on and after 10/01/2016 to reflect the ICD-10 Annual Code Updates. The following ICD-10 code(s) have undergone a descriptor change: Group 1 codes T82.817A, T82.817D, T82.817S, T82.827A, T82.827D, T82.827S, T82.837A, T82.837D, T82.837S, T82.847A, T82.847D, T82.847S, T82.857A, T82.857D, T82.857S, T82.867A, T82.867D, and T82.867S.
03/10/2016 R3 Article revised and published on 07/14/2016 to revise information for reporting PET Aß imaging through CED to include CPT codes 78811 or 78814, the corresponding tracer code A9586 or A9599, modifier Q0 or Q1, and ICD-10-CM diagnosis code Z00.6. Added reference to CR 8526. Updated the NCD reference in the Group 2 paragraph from NCD 220.6 to NCD 220.6.13 for FDG PET for Dementia and Neurodegenerative Diseases. Added the hyperlink to NCD 220.6.20 to the bottom of this article.
03/10/2016 R2 Article revised and published on 04/14/2016. The following duplicative paragraph has been removed from the Article Text section that is also listed in the Covered ICD-10 Codes section and a minor typographical error has also been corrected in this paragraph: It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted.
03/10/2016 R1 Article revised and published on 03/10/2016 effective for dates of service on and after 10/01/2015 to add several ICD-10 diagnoses codes to Group 1 and 2 as covered diagnoses. The following diagnosis codes were added to Group 1 codes: I21.01; I21.02; I21.21; I22.0; I22.1; I22.2; I22.8; I23.4; I23.5; I25.110; I25.111; I25.118; I25.6; I25.710; I25.711; I25.718; I25.720; I25.721; I25.728; I25.730; I25.731; I25.738; I25.750; I25.751; I25.758; I25.760; I25.761; I25.768; I25.790; I25.791; I25.798; I25.812; I42.0; I45.0; I45.19; I45.3; I46.2; I46.8; I47.0; I48.0; I48.1; I48.2; I48.3; I48.4; I49.1; I49.2; I97.111; I97.120; I97.121; I97.131; I97.191; R93.1; T82.817D; T82.817S; T82.827D; T82.827S; T82.837D; T82.837S; T82.847D; T82.847S; T82.857D; T82.857S; T82.867D; T82.867S; T82.897D; T82.897S; T86.23; T86.290; T86.298; T86.30; T86.31; T86.32; T86.33; T86.39; Z94.3. The following diagnosis codes were added to Group 2 codes: F05; G40.011; G40.019; G40.319; G40.A11; G40.A19; G40.B11; G40.B19; G40.803; G40.813; G40.814; G40.823; G40.824. Added reference to Transmittal 3227 for CR8614, dated April 2, 2015. Added language to clarify the applicable NCD references. Added hyperlinks to each applicable NCD. The following revisions are effective for dates of service on and after 3/10/2016; the following diagnoses codes were removed from Group 1 codes to be consistent with the applicable NCD indications: R06.83; T82.9XXA; T86.20; Z09; Z51.11; Z92.82; Z98.85. The following diagnosis codes were removed from Group 2 codes: G40.301. The following Bill Types were removed: 021X, 022X; 023X.
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