Description
All PET Scans require the use of radiopharmaceutical diagnostic imaging agent (tracer). Claims billed without the required Tracer HCPCS codes will be recovered as overpayments.
Affected Code(s)
PET SCAN CPT Codes - 78429, 78430, 78431, 78432, 78433, 78434, 78491, 78492, 78459, 78608, 78811, 78812, 78813, 78814, 78815, 78816
Tracer Codes – A9515, A9526, A9552, A9555, A9586, A9587, A9588, A9595, A9597, A9598, Q9982, Q9983
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. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 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
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.3.1- Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005; effective 09/07/2021
8. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.3.2- Tracer Codes Required for Positron Emission Tomography (PET Scans); Effective 09/07/2021
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
10. AMA CPT Codebook
11. HCPCS Level II Codebook