Billing and Coding: Positron Emission Tomography Scans Coverage - R34 - Article effective February 18, 2022

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

NCD: 220.6.17 - Positron Emission Tomography (FDG PET) for Oncologic Conditions

Effective Date: February 18, 2022

Summary of Article Changes: In the Article Text corrected the link to CR12613 and the effective date to 5-20-2022 under Sources

In the Group 14 Paragraph under ICD-10-CM Codes that Support Medical Necessity, indicated Z85.3 MUST be billed with either any of the C50.XXX or C79.81 and added the breast cancer diagnosis codes: C50.011-C50.012, C50.021-C50.022, C50111-C50.112, C50.121-C50.122, C50.211-C50.212, C50.221-C50.222, C50.311-50.312, C50.321-C50.322, C50.411-C50.412, C50.421-C50.422, C50.511-C50.512, C50.521-C50.522, C50.611-C50.612, C50.621-C50.6.22, C50.811-C50.812 and C50.821-C50.822 to the Group 14 Codes section.

Removed the following statements in the Groups 11 and 13 Paragraphs respectively, “Effective 09/10/2021, the NCCN Guidelines have been updated to allow PET/CT or PET/MRI with Fluciclovine F18 to be considered for equivocal results on initial bone imaging with the ‘PI’ modifier” and “Effective 09/10/2021, the NCCN Guidelines have been updated to allow PET/CT or PET/MRI with Fluciclovine F18 to be considered for equivocal results on initial bone imaging with the use of the ‘PI’ modifier” as the use of the ‘PI’ continues to be nationally non-cover per NCD 220.6.17 C.1a.

In the Group 1, 17 and 19 Paragraphs added the statement “Providers must amend the KX modifier on the claim to attest that the use of the PI modifier is per NCCN Guidelines” and the approved FDA label indications for each tracer.

In the Group 20 Paragraph added A9597 for LOCAMETZ® (kit for the preparation of gallium Ga 68 gozetotide injection) as payable with 78811-78816 and the 'PI' or 'PS' modifier, the approved FDA label indications for the tracer and added the statement “Providers must amend the KX modifier on the claim to attest that the use of the PI modifier is per NCCN Guidelines.” Also added the diagnosis codes listed below to the Group 20 Codes section.

  • C61 - Malignant neoplasm of prostate
  • R97.21 - Rising PSA following treatment for malignant neoplasm of prostate
  • Z85.46 - Personal history of malignant neoplasm of prostate

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To access a complete list of CMS NCDs, visit the National Coverage Determinations (NCDs) Alphabetical Index.

 

Last Updated Jun 16 , 2022