Local Coverage Article: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non- Oncologic Conditions (A53134)

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1 Local Coverage Article: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non- Oncologic Conditions (A53134) Contractor Information Contractor Name Novitas Solutions, Inc. Article Information General Information Article ID A53134 Original ICD-9 Article ID A47551 Article Title NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non- Oncologic Conditions AMA CPT / ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is Original Effective Date 10/01/2015 Revision Effective Date Revision Ending Date Retirement Date

2 published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Article Guidance Article Text: The CMS National Coverage Determinations (NCD) Manual, Internet-Only Manual Publication , Section 220.6, discusses Positron Emission Tomography (PET) Scans coverage. This contractor maintains billing and coding article A53132, NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions, to provide billing and coding information regarding the uses of PET scans for oncologic conditions. This article provides billing and coding information regarding several of the uses of PET scans for nononcologic conditions. Specifically, CMS NCD includes Section , PET for Perfusion of the Heart; Section , FDG PET for Myocardial Viability; Section , FDG PET for Refractory Seizures; and Section , FDG PET for Dementia and Neurodegenerative Diseases. This contractor has listed specific ICD-10-CM diagnosis codes as eligible for coverage for PET non-oncologic claims. Please note, however, 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. 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 has many other required elements for coverage, and they differ by indication. NCD Section B.1 discusses all of the requirements for an FDG PET scan to be considered 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 B.2 discusses all of the requirements for an FDG PET scan to be considered reasonable and necessary when used in patients with MCI or early dementia in the context of a CMS-approved clinical trial. NCD Section C basically states that all other uses of FDG PET for dementia remain non-covered. Medicare has recently concluded that the use of PET Aβ imaging could be promising in certain scenarios. Therefore, Medicare has decided to allow coverage for PET Aβ imaging (one PET Aβ scan per patient) through coverage with evidence development (CED) to: (1) develop better treatments or prevention strategies for AD, or, as a strategy to identify subpopulations at risk for developing AD, or (2) resolve clinically difficult differential diagnoses (e.g., frontotemporal

3 dementia (FTD) versus AD) where the use of PET Aβ imaging appears to improve health outcomes, when the patient is enrolled in an approved clinical study under CED. Please refer to NCD for complete coverage indications. 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. 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".) 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 this, 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. 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. CPT code is a non-covered service. HCPCS code A4641 is not an applicable tracer for PET scans. Positron Emission Tomography Reference Table CPT Tracer/Code Comment FDG/A9552 Not Applicable N-13/A9526 or Rb-82/A9555 N-13/A9526 or Rb-82/A9555 Not Applicable Not Applicable

4 78608 FDG/A9552 Covered indications: Alzheimer s disease/dementias, intractable seizures Note: This code is also covered for dedicated PET brain tumor imaging Not Applicable Nationally non-covered Other Comments 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. 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. Original JH ICD-9 Article A52202, Positron Emission Tomography (PET) Scans Used for Non- Oncologic Conditions. Coding Information 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. Bill Type Codes Information Table 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 083x Ambulatory Surgery Center 085x Critical Access Hospital Revenue Codes:

5 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. The Revenue Codes Information Table 0404 Other Imaging Services - Positron Emission Tomography CPT/HCPCS Codes Group 1 Paragraph: Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes. Group 1 Codes: CPT/HCPCS Codes Information Table A9526 A9552 A9555 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST AND/OR STRESS BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC EVALUATION NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 MILLICURIES Group 2 Paragraph: The following procedure codes are non-covered by Medicare. Group 2 Codes:

6 CPT/HCPCS Codes Information Table G0219 G0235 G0252 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION EVALUATION PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED INDICATIONS PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED PET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY, FOR INITIAL DIAGNOSIS OF BREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER (E.G. INITIAL STAGING OF AXILLARY LYMPH NODES) ICD-10 Codes that are Covered Group 1 Paragraph: It is the provider s responsibility to select codes carries 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. Medicare is establishing the following limited coverage for CPT/HCPCS codes 78459, 78491, and 78492: Group 1Codes ICD-10 Code Description I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure I20.0 Unstable angina I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I20.9 Angina pectoris, unspecified I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I21.4 Non-ST elevation (NSTEMI) myocardial infarction I24.0 Acute coronary thrombosis not resulting in myocardial infarction I24.1 Dressler's syndrome I24.8 Other forms of acute ischemic heart disease I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris

7 I25.2 Old myocardial infarction I25.3 Aneurysm of heart I25.41 Coronary artery aneurysm I25.42 Coronary artery dissection I25.5 Ischemic cardiomyopathy I Atherosclerosis of coronary artery bypass graft(s) without angina pectoris I Atherosclerosis of native coronary artery of transplanted heart without angina pectoris I25.82 Chronic total occlusion of coronary artery I25.83 Coronary atherosclerosis due to lipid rich plaque I25.84 Coronary atherosclerosis due to calcified coronary lesion I25.89 Other forms of chronic ischemic heart disease I25.9 Chronic ischemic heart disease, unspecified I35.0 Nonrheumatic aortic (valve) stenosis I35.1 Nonrheumatic aortic (valve) insufficiency I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency I35.8 Other nonrheumatic aortic valve disorders I35.9 Nonrheumatic aortic valve disorder, unspecified I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy I42.3 Endomyocardial (eosinophilic) disease I42.4 Endocardial fibroelastosis I42.5 Other restrictive cardiomyopathy I42.6 Alcoholic cardiomyopathy I42.7 Cardiomyopathy due to drug and external agent I42.8 Other cardiomyopathies I43 Cardiomyopathy in diseases classified elsewhere I44.2 Atrioventricular block, complete I44.30 Unspecified atrioventricular block I44.39 Other atrioventricular block I44.4 Left anterior fascicular block I44.5 Left posterior fascicular block I44.60 Unspecified fascicular block I44.69 Other fascicular block I44.7 Left bundle-branch block, unspecified I45.10 Unspecified right bundle-branch block I45.2 Bifascicular block I45.4 Nonspecific intraventricular block I46.9 Cardiac arrest, cause unspecified I47.1 Supraventricular tachycardia I47.2 Ventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified

8 I48.91 Unspecified atrial fibrillation I48.92 Unspecified atrial flutter I49.01 Ventricular fibrillation I49.02 Ventricular flutter I49.3 Ventricular premature depolarization I49.49 Other premature depolarization I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I51.1 Rupture of chordae tendineae, not elsewhere classified I51.2 Rupture of papillary muscle, not elsewhere classified I51.81 Takotsubo syndrome I51.89 Other ill-defined heart diseases I97.0 Postcardiotomy syndrome I Postprocedural cardiac insufficiency following cardiac surgery I Postprocedural heart failure following cardiac surgery I Other postprocedural cardiac functional disturbances following cardiac surgery R06.00 Dyspnea, unspecified R06.01 Orthopnea R06.02 Shortness of breath R06.09 Other forms of dyspnea R06.83 Snoring R06.89 Other abnormalities of breathing R07.2 Precordial pain R07.82 Intercostal pain R07.89 Other chest pain R07.9 Chest pain, unspecified R55 Syncope and collapse R93.8 Abnormal findings on diagnostic imaging of other specified body structures R93.9 Diagnostic imaging inconclusive due to excess body fat of patient

9 R94.31 Abnormal electrocardiogram [ECG] [EKG] T82.817A Embolism of cardiac prosthetic devices, implants and grafts, initial encounter T82.827A Fibrosis of cardiac prosthetic devices, implants and grafts, initial encounter T82.837A Hemorrhage of cardiac prosthetic devices, implants and grafts, initial encounter T82.847A Pain from cardiac prosthetic devices, implants and grafts, initial encounter T82.857A Stenosis of cardiac prosthetic devices, implants and grafts, initial encounter T82.867A Thrombosis of cardiac prosthetic devices, implants and grafts, initial encounter T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter T86.20 Unspecified complication of heart transplant T86.21 Heart transplant rejection T86.22 Heart transplant failure Z Encounter for preprocedural cardiovascular examination Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z51.11 Encounter for antineoplastic chemotherapy Z92.82 Status post administration of tpa (rtpa) in a different facility within the last 24 hours prior to admission to current facility Z94.1 Heart transplant status Z95.1 Presence of aortocoronary bypass graft Z98.61 Coronary angioplasty status Z98.85 Transplanted organ removal status Showing 1 to 118 of 118 entries in Group 1 Group 2 Paragraph: The following diagnoses support the medical necessity of brain PET for non-oncologic condition metabolic evaluation (CPT code 78608) as per the specific indications and limitations of the applicable sections of NCD Please see article A53132 for ICD-10-CM codes for oncologic condition uses. Group 2Codes ICD-10 Code Description F03.90 Unspecified dementia without behavioral disturbance G30.9 Alzheimer's disease, unspecified G31.01 Pick's disease G31.09 Other frontotemporal dementia G31.1 Senile degeneration of brain, not elsewhere classified G31.9 Degenerative disease of nervous system, unspecified

10 G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus G Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus G Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G Other epilepsy, intractable, without status epilepticus G Epilepsy, unspecified, intractable, with status epilepticus G Epilepsy, unspecified, intractable, without status epilepticus R41.2 Retrograde amnesia R41.3 Other amnesia R56.9 Unspecified convulsions Showing 1 to 20 of 20 entries in Group 2 ICD-10 Codes that are Not Covered Revision History Information Associated Documents Related Local Coverage Document(s) Related National Coverage Document(s) Statutory Requirements URL(s)

11 Rules and Regulations URL(s) CMS Manual Explanations URL(s) Other URL(s) Public Version(s) Updated on 08/06/2014 with effective dates 10/01/ Keywords Read the Article Disclaimer opens in new window