Billing and Coding: Positron Emission Tomography Scans Coverage - R24 - Article effective April 01, 2021 and Update effective January 01, 2021

This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: April 01, 2021
Summary of Article Changes: The following information was added effective for dates of service on or after January 01, 2021 in CPT/HCPCS Codes the  ICD-10 Codes that Support Medical Necessity sections respectively.

  • Group 1
    • A9591- Fluoroestradiol f 18, diagnostic, 1 millicurie and
    • C9068 - Copper Cu64 Dotatate diagnostic, 1 millicurie in the OPPS setting
  • Group 10 Contractor Determined Coverage for FDA Labeled Indications of Proprietary Radiopharmaceuticals Paragraph
    • Fluoroestradiol f 18, diagnostic, 1 millicurie
    • Copper Cu64 Dotatate diagnostic, 1 millicurie
  • Added the statements and diagnosis codes to Group 13
    • The following diagnoses are applicable to Fluoroestradiol f 18 injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9591 to bill for this service per CR 9861, effective 1/1/2021. Use the PS modifier and NOTE: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D, or R diagnosis codes.
    • Added diagnosis codes:
      • C79.81 - Secondary malignant neoplasm of breast
      • Z85.3 - Personal history of malignant neoplasm of breast
  • Added the statements and diagnosis codes to Group 14
    • The following diagnoses are applicable to A9597 (C9068 in the OPPS setting) for Copper Cu64 Dotatate injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9597/C9068 to bill for this service per CR 9861, effective 1/1/2021. Use the PI or PS modifier.
    • NOTE: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D, or R diagnosis codes.
    • Added diagnosis codes C7A.010, C7A.011, C7A.012, C7A.020, C7A.021, C7A.022, C7A.023, C7A.024, C7A.025, C7A.026, C7A.090, C7A.091, C7A.092, C7A.093, C7A.094, C7A.095, C7A.096, C7A.098, C7A.1, C7A.8, Z85.020, Z85.030, Z85.040, Z85.060, Z85.110, Z85.230 and Z85.520

Visit the Noridian Medicare Coverage Articles webpage and scroll to the bottom of the page to view this Future article available in the CMS MCD.

 

            Last Updated Thu, 18 Feb 2021 15:57:09 +0000