Description
Documentation will be reviewed to determine if Cardiac PET Scans meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary.
Affected Code(s)
78459, 78491, 78492, A9526, A9555, A9552, A9597, A9598
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 (e)(1)(B)- Advanced Diagnostic Imaging Services Defined
4. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1862 (a)(7) – Exclusions from Coverage and Medicare as Secondary Payer
5. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(s)(3) – Medical and Other Health Services
6. 42 CFR §405.929- Post-Payment Review
7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
8. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
9. 42 CFR §405.986- Good Cause for Reopening
10. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4- Coverage Determinations, Section 220.6.1- PET for Perfusion of the Heart
11. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4- Coverage Determinations, §220.6.8- FDG PET for Myocardial Viability
12. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §50- Nuclear Medicine (CPT 78000 – 79999)
13. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60- Positron Emission Tomography (PET) Scans- General Information
14. Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures, § 60.4 – PET Scans for imaging of the Perfusion of the Heart Using Rubidium 82 (RB 82)
15. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.9- Coverage of PET Scans for Myocardial Viability
16. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.11- Coverage of PET Scans for Perfusion of the Heart Using Ammonia N-13
17. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, § §3.1-3.6.6
18. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, §13.5.4- Reasonable and Necessary Provisions in LCDs
19. First Coast LCD L36209- Cardiology – non-emergent outpatient testing: exercise stress test, stress echo, MPI SPECT, and cardiac PET, Effective 10/01/2015; Retired 03/15/2020
20. First Coast LCD L38396 – Cardiology Non-emergent Outpatient Stress Testing, Effective 03/15/2020; Revised 4/25/2021
21. First Coast LCA A56952 – Billing and Coding: Cardiology – Non-emergent Outpatient Stress Testing, Effective 03/16/2020, Revised 10/01/2023
22. AMA CPT Codebook
23. Annual HCPCS Manual, Coding Guidelines HCPCS Level II Codebook