Local Coverage Article Billing and Coding

Billing and Coding: Positron Emission Tomography Scans Coverage

A54668

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Article ID
A54668
Article Title
Billing and Coding: Positron Emission Tomography Scans Coverage
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
02/18/2022
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

CMS National Coverage Determination, 220.6

Article Guidance

Article Text

This article describes the least restrictive coverage possible. Providers must read the entire NCD and related Internet Only Manual (IOM) sections (see "Sources" at end of this article) in order to correctly understand and apply the following coding guidance. In some cases, depending on the clinical scenario, the same diagnosis code describes a condition that may be covered, covered with evidence development only, both, or non-covered. In these situations, the code will appear as covered, the least restrictive coverage possible under any circumstances, in this article.

PET Scan Procedure
Positron Emission Tomography (PET) is a minimally invasive diagnostic imaging procedure used to evaluate metabolism in normal tissue as well as in diseased tissues in conditions such as cancer, ischemic heart disease, and some neurologic disorders. A radiopharmaceutical is injected into the patient that gives off sub-atomic particles, known as positrons, as it decays. PET uses a positron camera (tomograph) to measure the decay of the radiopharmaceutical. The rate of decay provides biochemical information on the metabolism of the tissue being studied.

Indications and Limitations of Coverage
1. The following sections cover the codes used to describe PET scans and the diagnoses that may justify use of the scan if all other Medicare requirements for coverage are met. Details of Medicare coverage requirements are NOT quoted in this article. Providers should familiarize themselves with the NCD (IOM Medicare National Coverage Determination (NCD) Manual, Publication 100-03, Chapter 1, Part 4, Section 220.6.1, 220.6.8, 220.6.9, 220.6.13, 220.6.17, 220.6.19 and 220.6.20) on PET Scans, which is the source of all information in this article.

Unless otherwise indicated, the clinical conditions below are covered when PET utilizes FDG as a tracer.

2. Any use and all uses of PET scans that are not specifically listed in the NCD listed above may be covered per local MAC discretion. Providers are encouraged to review the entire CMS NCD for PET Scans at: Medicare National Coverage Determination Manual, Chapter 1, Part 4 on the CMS Web site for further details and clarification of coverage. Providers are to bill G0235 for non-covered indications.

3. When PET Scans are performed in conjunction with a CMS-approved clinical trial or for an indication reimbursed under “Coverage with Evidence Development” (CED), providers must append the Q0 or Q1 modifier to the appropriate CPT code.

Q0 (Q zero) Investigational clinical trial service provided in a clinical research study that is in an approved clinical research study.

Q1 (Q one) Routine clinical Service provided in a clinical research study that is in an approved clinical research study.

Institutional claims must also include diagnosis code Z00.6 and condition code 30 to denote clinical trial.

4. Claims for FDG PET imaging for oncologic indications for initial treatment strategy must include the “PI” modifier. Claims for FDG PET imaging for oncologic indications for subsequent strategy must include the “PS” modifier.

PI - PET or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.

PS - PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy.

CPT/HCPCS Providers are expected to select the procedure code appropriate to the diagnosis of the clinical condition documented in the patient records.

Sources:
Internet Only Manual (IOM) Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 4, Section 220.6
IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 13, Section 60.3
• Technical Direction Letter (TDL)-13390, 06-26-2013
CMS Change Request (CR) 8381, 08-02-2013
CR 8526, 02-06-2014
CR 8526, 03-27-2014
CR 8197, 03-15-2013
CR 8381, 08-02-2013
CR 9486, 12-15-2015
CR 9861, 11-08-2016
CR 9930, 11-22-2016
CR 11655, 02-20-2020
CR12613, 05-20-2022

Effective for dates of service on or after December 15, 2017, coverage under CED of NaF-18 PET to identify bone metastasis of cancer reverts to a national non-coverage decision.

Coding Information

CPT/HCPCS Codes

Group 1

(36 Codes)
Group 1 Paragraph

Note:
• CPT code 78609 is a non-covered service, effective January 28, 2005.
• HCPCS code G0235 is to be billed for non-covered indications.
• Effective January 1, 2008, HCPCS code A4641 is not applicable for PET Scans.
•A9580 is non-covered effective 12/15/2017.

HCPCS codes A9597 or A9598, whichever is applicable, should be used to bill a new diagnostic radiopharmaceutical until the new diagnostic radiopharmaceutical has been granted pass-through status and a C-code has been assigned. They are assigned status indicator “N” in OPPS and, therefore, the payment for a diagnostic radiopharmaceutical assigned to any of these HCPCS codes is packaged into the payment for the associated service, per CR 9930.

HCPCS codes A9597 or A9598 may only be used to bill for contractor approved coverage of FDA labeled indications of proprietary radiopharmaceuticals. Refer to the end of this article for a listing of Noridian approved proprietary radiopharmaceuticals.

 

 

Group 1 Codes
CodeDescription
78429 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED), SINGLE STUDY; WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY TRANSMISSION SCAN
78430 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC), WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY TRANSMISSION SCAN
78431 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED); MULTIPLE STUDIES AT REST AND STRESS (EXERCISE OR PHARMACOLOGIC), WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY TRANSMISSION SCAN
78432 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), COMBINED PERFUSION WITH METABOLIC EVALUATION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED), DUAL RADIOTRACER (EG, MYOCARDIAL VIABILITY);
78433 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), COMBINED PERFUSION WITH METABOLIC EVALUATION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED), DUAL RADIOTRACER (EG, MYOCARDIAL VIABILITY); WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY TRANSMISSION SCAN
78434 ABSOLUTE QUANTITATION OF MYOCARDIAL BLOOD FLOW (AQMBF), POSITRON EMISSION TOMOGRAPHY (PET), REST AND PHARMACOLOGIC STRESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
78459 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED), SINGLE STUDY;
78491 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC)
78492 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED); MULTIPLE STUDIES AT REST AND STRESS (EXERCISE OR PHARMACOLOGIC)
78608 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC EVALUATION
78609 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION EVALUATION
78811 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK)
78812 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH
78813 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY
78814 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK)
78815 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH
78816 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY
A4641 RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED
A9515 CHOLINE C-11, DIAGNOSTIC, PER STUDY DOSE UP TO 20 MILLICURIES
A9526 NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES
A9552 FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES
A9555 RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 MILLICURIES
A9580 SODIUM FLUORIDE F-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES
A9586 FLORBETAPIR F18, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES
A9587 GALLIUM GA-68, DOTATATE, DIAGNOSTIC, 0.1 MILLICURIE
A9588 FLUCICLOVINE F-18, DIAGNOSTIC, 1 MILLICURIE
A9591 FLUOROESTRADIOL F 18, DIAGNOSTIC, 1 MILLICURIE
A9592 COPPER CU-64, DOTATATE, DIAGNOSTIC, 1 MILLICURIE
A9593 GALLIUM GA-68 PSMA-11, DIAGNOSTIC, (UCSF), 1 MILLICURIE
A9594 GALLIUM GA-68 PSMA-11, DIAGNOSTIC, (UCLA), 1 MILLICURIE
A9595 PIFLUFOLASTAT F-18, DIAGNOSTIC, 1 MILLICURIE
A9597 POSITRON EMISSION TOMOGRAPHY RADIOPHARMACEUTICAL, DIAGNOSTIC, FOR TUMOR IDENTIFICATION, NOT OTHERWISE CLASSIFIED
A9598 POSITRON EMISSION TOMOGRAPHY RADIOPHARMACEUTICAL, DIAGNOSTIC, FOR NON-TUMOR IDENTIFICATION, NOT OTHERWISE CLASSIFIED
G0235 PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED
Q9982 FLUTEMETAMOL F18, DIAGNOSTIC, PER STUDY DOSE, UP TO 5 MILLICURIES
Q9983 FLORBETABEN F18, DIAGNOSTIC, PER STUDY DOSE, UP TO 8.1 MILLICURIES

Group 2

(3 Codes)
Group 2 Paragraph

Tracer Codes Required for PET Scans (Packaged reimbursement for tracers):

The following tracer codes are applicable only to CPT 78430, 78431, 78432, 78433, 78434, 78491 and 78492. They cannot be reported with any other code.

*Effective January 1, 2008, tracer code A4641 is not applicable for PET Scans.

Group 2 Codes
CodeDescription
A4641 RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED
A9526 NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES
A9555 RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 MILLICURIES

Group 3

(2 Codes)
Group 3 Paragraph

Tracer Codes Required for PET Scans (Packaged reimbursement for tracers):

The following tracer codes are applicable only to CPT 78429, 78432, 78433, 78459, 78608, 78811-78816.
They cannot be reported with any other code:

*Effective January 1, 2008, tracer code A4641 is not applicable for PET Scans.

Group 3 Codes
CodeDescription
A4641 RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED
A9552 FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES

Group 4

(3 Codes)
Group 4 Paragraph

Tracer Codes Required for PET Scans (Packaged reimbursement for tracers):

Effective for claims with dates of service on/after September 27, 2013
Medicare will allow one beta amyloid brain PET scan per patient under coverage with evidence development (CED). The following tracer codes are applicable only to 78811 and 78814. Claims must contain Q0 and/or Q1 modifiers. Q9982 and Q9983 are effective for dates of service on/after 07/01/2016 per Change Request 9751.

Group 4 Codes
CodeDescription
A9586 FLORBETAPIR F18, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES
Q9982 FLUTEMETAMOL F18, DIAGNOSTIC, PER STUDY DOSE, UP TO 5 MILLICURIES
Q9983 FLORBETABEN F18, DIAGNOSTIC, PER STUDY DOSE, UP TO 8.1 MILLICURIES

CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
PI POSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORM THE INITIAL TREATMENT STRATEGY OF TUMORS THAT ARE BIOPSY PROVEN OR STRONGLY SUSPECTED OF BEING CANCEROUS BASED ON OTHER DIAGNOSTIC TESTING
PS POSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORM THE SUBSEQUENT TREATMENT STRATEGY OF CANCEROUS TUMORS WHEN THE BENEFICIARY'S TREATING PHYSICIAN DETERMINES THAT THE PET STUDY IS NEEDED TO INFORM SUBSEQUENT ANTI-TUMOR STRATEGY
Q0 INVESTIGATIONAL CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN APPROVED CLINICAL RESEARCH STUDY
Q1 ROUTINE CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN APPROVED CLINICAL RESEARCH STUDY

ICD-10-CM Codes that Support Medical Necessity

Group 1

(106 Codes)
Group 1 Paragraph

Noridian has determined that the following ICD-10-CM codes support medical necessity for PET scan coverage if all other requirements of coverage are met.

For CPT Codes 78429,78432, 78433 or 78459, use the tracer A9552 and for CPT codes 78430, 78431, 78432, 78433, 78434, 78491 or 78492 use the tracer A9526 or A9555 with the diagnosis codes listed below.

Note: 78432 and 78433 can be billed with any of the tracers A9526, A9552 or A9555.

 

Group 1 Codes
CodeDescription
I11.0 Hypertensive heart disease with heart failure
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I20.0 Unstable angina
I20.1 Angina pectoris with documented spasm
I20.8 Other forms of angina pectoris
I20.9 Angina pectoris, unspecified
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
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
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
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
I21.9 Acute myocardial infarction, unspecified
I21.A1 Myocardial infarction type 2
I21.A9 Other myocardial infarction type
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
I24.0 Acute coronary thrombosis not resulting in myocardial infarction
I24.1 Dressler's syndrome
I24.8 Other forms of acute ischemic heart disease
I24.9 Acute ischemic heart disease, unspecified
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.2 Old myocardial infarction
I25.3 Aneurysm of heart
I25.41 Coronary artery aneurysm
I25.42 Coronary artery dissection
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris
I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris
I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris
I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris
I25.812 Atherosclerosis of bypass graft of 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
I44.7 Left bundle-branch block, unspecified
I47.0 Re-entry ventricular arrhythmia
I47.2 Ventricular tachycardia
I48.11 Longstanding persistent atrial fibrillation
I48.19 Other persistent atrial fibrillation
I48.20 Chronic atrial fibrillation, unspecified
I48.21 Permanent atrial fibrillation
I50.1 Left ventricular failure, unspecified
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
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
R93.1 Abnormal findings on diagnostic imaging of heart and coronary circulation
R94.31 Abnormal electrocardiogram [ECG] [EKG]

Group 2

(7 Codes)
Group 2 Paragraph

For CPT Code 78608 (Non-oncologic indications including clinical trials):

A9552 is used for the tracer.

*Note: Effective for dates of service on or after September 15, 2004, Medicare will cover FDG PET scans for a differential diagnosis of frontotemporal dementia (FTD) and Alzheimer's disease OR; its use in a CMS-approved practical clinical trial focused on the utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative diseases. Please refer to NCD 220.6.13 for complete coverage conditions and clinical trial requirements. Claims must include diagnosis code Z00.6, modifier Q0 or Q1 to denote clinical trial and institutional claims must also include condition code 30.

Providers/practitioners should notify Noridian if they become approved to participate in a clinical trial by emailing Noridian at: IDErequests@noridian.com.

Medical record documentation must include:

  • Date of onset of symptoms;
  • Diagnosis of clinical syndrome (normal aging, mild cognitive impairment or MCI: mild, moderate or severe dementia);
  • Mini mental status exam (MMSE) or similar test score;
  • Presumptive cause (possible, probably, uncertain AD);
  • Any neuropsychological testing performed;
  • Results of any structural imaging (MRI, CT) performed;
  • Relevant laboratory tests (B12, thyroid hormone); and
  • Number and name of prescribed medications.

**Note: When billing F05, a secondary diagnosis of F03.90 is required per CR 8614, 4/2/2015. Use G30.9 instead of G30.0, G30.1 and G30.8 for Alzheimer’s Disease G31.9 instead of G31.09, G31.1, G31.84, G31.85 & R41.1 for dementia outside of a clinical trial per CR 12376.

Group 2 Codes
CodeDescription
F03.90 Unspecified dementia without behavioral disturbance
F05 Delirium due to known physiological condition
G30.9 Alzheimer's disease, unspecified
G31.01 Pick's disease
G31.9 Degenerative disease of nervous system, unspecified
R41.2 Retrograde amnesia
R41.3 Other amnesia

Group 3

(26 Codes)
Group 3 Paragraph

Per NCD 220.6.9, the diagnosis codes listed below are covered for pre-surgical evaluation for the purpose for the localization of a focus of refractory seizure activity using A9552 as the tracer.

Limitations: Covered only for pre-surgical evaluation.

Documentation that these conditions are met should be maintained by the referring physician in the beneficiary's medical record, as is normal business practice.

Group 3 Codes
CodeDescription
G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus
G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.A01 Absence epileptic syndrome, not intractable, with status epilepticus
G40.A09 Absence epileptic syndrome, not intractable, without status epilepticus
G40.A11 Absence epileptic syndrome, intractable, with status epilepticus
G40.A19 Absence epileptic syndrome, intractable, without status epilepticus
G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus
G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.803 Other epilepsy, intractable, with status epilepticus
G40.804 Other epilepsy, intractable, without status epilepticus
G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.823 Epileptic spasms, intractable, with status epilepticus
G40.824 Epileptic spasms, intractable, without status epilepticus
G40.89 Other seizures
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus

Group 4

(14 Codes)
Group 4 Paragraph

Requirements for Beta Amyloid PET in Dementia and Neurogenerative Disease:

Effective for claims with dates of service on/after September 27, 2013, Medicare will allow one beta amyloid imaging PET scan per patient under the coverage with evidence development guidelines (CED), per Change Request 8526, 02/06/2014.

For CPT codes 78811 or 78814 with beta amyloid tracer (A9586, Q9982 or Q9983), the following diagnoses are covered and must also be billed in addition to Z00.6 and modifier Q0 or Q1:

Group 4 Codes
CodeDescription
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F03.90 Unspecified dementia without behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
G31.01 Pick's disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
G31.84 Mild cognitive impairment, so stated
G31.85 Corticobasal degeneration
R41.1 Anterograde amnesia
R41.2 Retrograde amnesia
R41.3 Other amnesia

Group 5

(559 Codes)
Group 5 Paragraph

In addition to the noted indications for PET scans of the brain and heart, the following six diagnosis lists apply to coverage of PET scanning with FDG (A9552) for oncological purposes. NB: This instruction may not be used apart from the NCD which provides additional and more in-depth details for the reporting of each diagnosis.

List I (For CPT codes 78811, 78812, 78813, 78814, 78815, or 78816)

*There is no payment for the initial diagnosis of cervical cancer with PET. These codes should not be billed for such utilization of PET (C53.0-C53.8).

The following diagnoses may be covered for initial and/or subsequent treatment strategies when all other Medicare requirements are met. The modifiers "PI" or "PS" must appear on the claim.

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.

Group 5 Codes
CodeDescription
C00.0 Malignant neoplasm of external upper lip
C00.1 Malignant neoplasm of external lower lip
C00.3 Malignant neoplasm of upper lip, inner aspect
C00.4 Malignant neoplasm of lower lip, inner aspect
C00.6 Malignant neoplasm of commissure of lip, unspecified
C00.8 Malignant neoplasm of overlapping sites of lip
C01 Malignant neoplasm of base of tongue
C02.0 Malignant neoplasm of dorsal surface of tongue
C02.1 Malignant neoplasm of border of tongue
C02.2 Malignant neoplasm of ventral surface of tongue
C02.4 Malignant neoplasm of lingual tonsil
C02.8 Malignant neoplasm of overlapping sites of tongue
C03.0 Malignant neoplasm of upper gum
C03.1 Malignant neoplasm of lower gum
C04.0 Malignant neoplasm of anterior floor of mouth
C04.1 Malignant neoplasm of lateral floor of mouth
C04.8 Malignant neoplasm of overlapping sites of floor of mouth
C05.0 Malignant neoplasm of hard palate
C05.1 Malignant neoplasm of soft palate
C05.2 Malignant neoplasm of uvula
C05.8 Malignant neoplasm of overlapping sites of palate
C06.0 Malignant neoplasm of cheek mucosa
C06.1 Malignant neoplasm of vestibule of mouth
C06.2 Malignant neoplasm of retromolar area
C06.89 Malignant neoplasm of overlapping sites of other parts of mouth
C07 Malignant neoplasm of parotid gland
C08.0 Malignant neoplasm of submandibular gland
C08.1 Malignant neoplasm of sublingual gland
C09.0 Malignant neoplasm of tonsillar fossa
C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior)
C09.8 Malignant neoplasm of overlapping sites of tonsil
C09.9 Malignant neoplasm of tonsil, unspecified
C10.0 Malignant neoplasm of vallecula
C10.1 Malignant neoplasm of anterior surface of epiglottis
C10.2 Malignant neoplasm of lateral wall of oropharynx
C10.3 Malignant neoplasm of posterior wall of oropharynx
C10.4 Malignant neoplasm of branchial cleft
C10.8 Malignant neoplasm of overlapping sites of oropharynx
C11.0 Malignant neoplasm of superior wall of nasopharynx
C11.1 Malignant neoplasm of posterior wall of nasopharynx
C11.2 Malignant neoplasm of lateral wall of nasopharynx
C11.3 Malignant neoplasm of anterior wall of nasopharynx
C11.8 Malignant neoplasm of overlapping sites of nasopharynx
C12 Malignant neoplasm of pyriform sinus
C13.0 Malignant neoplasm of postcricoid region
C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect
C13.2 Malignant neoplasm of posterior wall of hypopharynx
C13.8 Malignant neoplasm of overlapping sites of hypopharynx
C14.2 Malignant neoplasm of Waldeyer's ring
C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx
C15.3 Malignant neoplasm of upper third of esophagus
C15.4 Malignant neoplasm of middle third of esophagus
C15.5 Malignant neoplasm of lower third of esophagus
C15.8 Malignant neoplasm of overlapping sites of esophagus
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C30.0 Malignant neoplasm of nasal cavity
C30.1 Malignant neoplasm of middle ear
C31.0 Malignant neoplasm of maxillary sinus
C31.1 Malignant neoplasm of ethmoidal sinus
C31.2 Malignant neoplasm of frontal sinus
C31.3 Malignant neoplasm of sphenoid sinus
C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
C32.0 Malignant neoplasm of glottis
C32.1 Malignant neoplasm of supraglottis
C32.2 Malignant neoplasm of subglottis
C32.3 Malignant neoplasm of laryngeal cartilage
C32.8 Malignant neoplasm of overlapping sites of larynx
C33 Malignant neoplasm of trachea
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C41.0 Malignant neoplasm of bones of skull and face
C41.1 Malignant neoplasm of mandible
C43.0 Malignant melanoma of lip
C43.111 Malignant melanoma of right upper eyelid, including canthus
C43.112 Malignant melanoma of right lower eyelid, including canthus
C43.121 Malignant melanoma of left upper eyelid, including canthus
C43.122 Malignant melanoma of left lower eyelid, including canthus
C43.21 Malignant melanoma of right ear and external auricular canal
C43.22 Malignant melanoma of left ear and external auricular canal
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C43.4 Malignant melanoma of scalp and neck
C43.51 Malignant melanoma of anal skin
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
C43.61 Malignant melanoma of right upper limb, including shoulder
C43.62 Malignant melanoma of left upper limb, including shoulder
C43.71 Malignant melanoma of right lower limb, including hip
C43.72 Malignant melanoma of left lower limb, including hip
C43.8 Malignant melanoma of overlapping sites of skin
C44.00 Unspecified malignant neoplasm of skin of lip
C44.01 Basal cell carcinoma of skin of lip
C44.02 Squamous cell carcinoma of skin of lip
C44.09 Other specified malignant neoplasm of skin of lip
C44.1021 Unspecified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1022 Unspecified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1091 Unspecified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1092 Unspecified malignant neoplasm of skin of left lower eyelid, including canthus
C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.1191 Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus
C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus
C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus
C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus
C44.1921 Other specified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1922 Other specified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1991 Other specified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1992 Other specified malignant neoplasm of skin of left lower eyelid, including canthus
C44.202 Unspecified malignant neoplasm of skin of right ear and external auricular canal
C44.209 Unspecified malignant neoplasm of skin of left ear and external auricular canal
C44.212 Basal cell carcinoma of skin of right ear and external auricular canal
C44.219 Basal cell carcinoma of skin of left ear and external auricular canal
C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal
C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal
C44.292 Other specified malignant neoplasm of skin of right ear and external auricular canal
C44.299 Other specified malignant neoplasm of skin of left ear and external auricular canal
C44.301 Unspecified malignant neoplasm of skin of nose
C44.309 Unspecified malignant neoplasm of skin of other parts of face
C44.311 Basal cell carcinoma of skin of nose
C44.319 Basal cell carcinoma of skin of other parts of face
C44.321 Squamous cell carcinoma of skin of nose
C44.329 Squamous cell carcinoma of skin of other parts of face
C44.391 Other specified malignant neoplasm of skin of nose
C44.399 Other specified malignant neoplasm of skin of other parts of face
C44.40 Unspecified malignant neoplasm of skin of scalp and neck
C44.42 Squamous cell carcinoma of skin of scalp and neck
C44.49 Other specified malignant neoplasm of skin of scalp and neck
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C53.0 Malignant neoplasm of endocervix
C53.1 Malignant neoplasm of exocervix
C53.8 Malignant neoplasm of overlapping sites of cervix uteri
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.3 Malignant neoplasm of bilateral ovaries
C73 Malignant neoplasm of thyroid gland
C75.4 Malignant neoplasm of carotid body
C76.0 Malignant neoplasm of head, face and neck
C81.01 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.02 Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes
C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes
C81.04 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.05 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.06 Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes
C81.07 Nodular lymphocyte predominant Hodgkin lymphoma, spleen
C81.08 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites
C81.09 Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites
C81.11 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes
C81.13 Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes
C81.14 Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.15 Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.16 Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes
C81.17 Nodular sclerosis Hodgkin lymphoma, spleen
C81.18 Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites
C81.19 Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites
C81.21 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes
C81.23 Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes
C81.24 Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.25 Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.26 Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes
C81.27 Mixed cellularity Hodgkin lymphoma, spleen
C81.28 Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites
C81.29 Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites
C81.31 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes
C81.33 Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes
C81.34 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.35 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.36 Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes
C81.37 Lymphocyte depleted Hodgkin lymphoma, spleen
C81.38 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites
C81.39 Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites
C81.41 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes
C81.43 Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes
C81.44 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.45 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.46 Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes
C81.47 Lymphocyte-rich Hodgkin lymphoma, spleen
C81.48 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites
C81.49 Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites
C81.71 Other Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.72 Other Hodgkin lymphoma, intrathoracic lymph nodes
C81.73 Other Hodgkin lymphoma, intra-abdominal lymph nodes
C81.74 Other Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.75 Other Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.76 Other Hodgkin lymphoma, intrapelvic lymph nodes
C81.77 Other Hodgkin lymphoma, spleen
C81.78 Other Hodgkin lymphoma, lymph nodes of multiple sites
C81.79 Other Hodgkin lymphoma, extranodal and solid organ sites
C81.91 Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
C81.92 Hodgkin lymphoma, unspecified, intrathoracic lymph nodes
C81.93 Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes
C81.94 Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb
C81.95 Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb
C81.96 Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
C81.97 Hodgkin lymphoma, unspecified, spleen
C81.98 Hodgkin lymphoma, unspecified, lymph nodes of multiple sites
C81.99 Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C82.01 Follicular lymphoma grade I, lymph nodes of head, face, and neck
C82.02 Follicular lymphoma grade I, intrathoracic lymph nodes
C82.03 Follicular lymphoma grade I, intra-abdominal lymph nodes
C82.04 Follicular lymphoma grade I, lymph nodes of axilla and upper limb
C82.05 Follicular lymphoma grade I, lymph nodes of inguinal region and lower limb
C82.06 Follicular lymphoma grade I, intrapelvic lymph nodes
C82.07 Follicular lymphoma grade I, spleen
C82.08 Follicular lymphoma grade I, lymph nodes of multiple sites
C82.09 Follicular lymphoma grade I, extranodal and solid organ sites
C82.11 Follicular lymphoma grade II, lymph nodes of head, face, and neck
C82.12 Follicular lymphoma grade II, intrathoracic lymph nodes
C82.13 Follicular lymphoma grade II, intra-abdominal lymph nodes
C82.14 Follicular lymphoma grade II, lymph nodes of axilla and upper limb
C82.15 Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb
C82.16 Follicular lymphoma grade II, intrapelvic lymph nodes
C82.17 Follicular lymphoma grade II, spleen
C82.18 Follicular lymphoma grade II, lymph nodes of multiple sites
C82.19 Follicular lymphoma grade II, extranodal and solid organ sites
C82.21 Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck
C82.22 Follicular lymphoma grade III, unspecified, intrathoracic lymph nodes
C82.23 Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes
C82.24 Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb
C82.25 Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb
C82.26 Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes
C82.27 Follicular lymphoma grade III, unspecified, spleen
C82.28 Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites
C82.29 Follicular lymphoma grade III, unspecified, extranodal and solid organ sites
C82.31 Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck
C82.32 Follicular lymphoma grade IIIa, intrathoracic lymph nodes
C82.33 Follicular lymphoma grade IIIa, intra-abdominal lymph nodes
C82.34 Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb
C82.35 Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb
C82.36 Follicular lymphoma grade IIIa, intrapelvic lymph nodes
C82.37 Follicular lymphoma grade IIIa, spleen
C82.38 Follicular lymphoma grade IIIa, lymph nodes of multiple sites
C82.39 Follicular lymphoma grade IIIa, extranodal and solid organ sites
C82.41 Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck
C82.42 Follicular lymphoma grade IIIb, intrathoracic lymph nodes
C82.43 Follicular lymphoma grade IIIb, intra-abdominal lymph nodes
C82.44 Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb
C82.45 Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb
C82.46 Follicular lymphoma grade IIIb, intrapelvic lymph nodes
C82.47 Follicular lymphoma grade IIIb, spleen
C82.48 Follicular lymphoma grade IIIb, lymph nodes of multiple sites
C82.49 Follicular lymphoma grade IIIb, extranodal and solid organ sites
C82.51 Diffuse follicle center lymphoma, lymph nodes of head, face, and neck
C82.52 Diffuse follicle center lymphoma, intrathoracic lymph nodes
C82.53 Diffuse follicle center lymphoma, intra-abdominal lymph nodes
C82.54 Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb
C82.55 Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb
C82.56 Diffuse follicle center lymphoma, intrapelvic lymph nodes
C82.57 Diffuse follicle center lymphoma, spleen
C82.58 Diffuse follicle center lymphoma, lymph nodes of multiple sites
C82.59 Diffuse follicle center lymphoma, extranodal and solid organ sites
C82.61 Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck
C82.62 Cutaneous follicle center lymphoma, intrathoracic lymph nodes
C82.63 Cutaneous follicle center lymphoma, intra-abdominal lymph nodes
C82.64 Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb
C82.65 Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb
C82.66 Cutaneous follicle center lymphoma, intrapelvic lymph nodes
C82.67 Cutaneous follicle center lymphoma, spleen
C82.68 Cutaneous follicle center lymphoma, lymph nodes of multiple sites
C82.69 Cutaneous follicle center lymphoma, extranodal and solid organ sites
C82.81 Other types of follicular lymphoma, lymph nodes of head, face, and neck
C82.82 Other types of follicular lymphoma, intrathoracic lymph nodes
C82.83 Other types of follicular lymphoma, intra-abdominal lymph nodes
C82.84 Other types of follicular lymphoma, lymph nodes of axilla and upper limb
C82.85 Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb
C82.86 Other types of follicular lymphoma, intrapelvic lymph nodes
C82.87 Other types of follicular lymphoma, spleen
C82.88 Other types of follicular lymphoma, lymph nodes of multiple sites
C82.89 Other types of follicular lymphoma, extranodal and solid organ sites
C82.91 Follicular lymphoma, unspecified, lymph nodes of head, face, and neck
C82.92 Follicular lymphoma, unspecified, intrathoracic lymph nodes
C82.93 Follicular lymphoma, unspecified, intra-abdominal lymph nodes
C82.94 Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb
C82.95 Follicular lymphoma, unspecified, lymph nodes of inguinal region and lower limb
C82.96 Follicular lymphoma, unspecified, intrapelvic lymph nodes
C82.97 Follicular lymphoma, unspecified, spleen
C82.98 Follicular lymphoma, unspecified, lymph nodes of multiple sites
C82.99 Follicular lymphoma, unspecified, extranodal and solid organ sites
C83.01 Small cell B-cell lymphoma, lymph nodes of head, face, and neck
C83.02 Small cell B-cell lymphoma, intrathoracic lymph nodes
C83.03 Small cell B-cell lymphoma, intra-abdominal lymph nodes
C83.04 Small cell B-cell lymphoma, lymph nodes of axilla and upper limb
C83.05 Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb
C83.06 Small cell B-cell lymphoma, intrapelvic lymph nodes
C83.07 Small cell B-cell lymphoma, spleen
C83.08 Small cell B-cell lymphoma, lymph nodes of multiple sites
C83.09 Small cell B-cell lymphoma, extranodal and solid organ sites
C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck
C83.12 Mantle cell lymphoma, intrathoracic lymph nodes
C83.13 Mantle cell lymphoma, intra-abdominal lymph nodes
C83.14 Mantle cell lymphoma, lymph nodes of axilla and upper limb
C83.15 Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
C83.16 Mantle cell lymphoma, intrapelvic lymph nodes
C83.17 Mantle cell lymphoma, spleen
C83.18 Mantle cell lymphoma, lymph nodes of multiple sites
C83.19 Mantle cell lymphoma, extranodal and solid organ sites
C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
C83.32 Diffuse large B-cell lymphoma, intrathoracic lymph nodes
C83.33 Diffuse large B-cell lymphoma, intra-abdominal lymph nodes
C83.34 Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb
C83.35 Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb
C83.36 Diffuse large B-cell lymphoma, intrapelvic lymph nodes
C83.37 Diffuse large B-cell lymphoma, spleen
C83.38 Diffuse large B-cell lymphoma, lymph nodes of multiple sites
C83.39 Diffuse large B-cell lymphoma, extranodal and solid organ sites
C83.51 Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck
C83.52 Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes
C83.53 Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes
C83.54 Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb
C83.55 Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb
C83.56 Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes
C83.57 Lymphoblastic (diffuse) lymphoma, spleen
C83.58 Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites
C83.59 Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites
C83.71 Burkitt lymphoma, lymph nodes of head, face, and neck
C83.72 Burkitt lymphoma, intrathoracic lymph nodes
C83.73 Burkitt lymphoma, intra-abdominal lymph nodes
C83.74 Burkitt lymphoma, lymph nodes of axilla and upper limb
C83.75 Burkitt lymphoma, lymph nodes of inguinal region and lower limb
C83.76 Burkitt lymphoma, intrapelvic lymph nodes
C83.77 Burkitt lymphoma, spleen
C83.78 Burkitt lymphoma, lymph nodes of multiple sites
C83.79 Burkitt lymphoma, extranodal and solid organ sites
C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck
C83.82 Other non-follicular lymphoma, intrathoracic lymph nodes
C83.83 Other non-follicular lymphoma, intra-abdominal lymph nodes
C83.84 Other non-follicular lymphoma, lymph nodes of axilla and upper limb
C83.85 Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb
C83.86 Other non-follicular lymphoma, intrapelvic lymph nodes
C83.87 Other non-follicular lymphoma, spleen
C83.88 Other non-follicular lymphoma, lymph nodes of multiple sites
C83.89 Other non-follicular lymphoma, extranodal and solid organ sites
C83.91 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck
C83.92 Non-follicular (diffuse) lymphoma, unspecified, intrathoracic lymph nodes
C83.93 Non-follicular (diffuse) lymphoma, unspecified, intra-abdominal lymph nodes
C83.94 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of axilla and upper limb
C83.95 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of inguinal region and lower limb
C83.96 Non-follicular (diffuse) lymphoma, unspecified, intrapelvic lymph nodes
C83.97 Non-follicular (diffuse) lymphoma, unspecified, spleen
C83.98 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of multiple sites
C83.99 Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites
C84.01 Mycosis fungoides, lymph nodes of head, face, and neck
C84.02 Mycosis fungoides, intrathoracic lymph nodes
C84.03 Mycosis fungoides, intra-abdominal lymph nodes
C84.04 Mycosis fungoides, lymph nodes of axilla and upper limb
C84.05 Mycosis fungoides, lymph nodes of inguinal region and lower limb
C84.06 Mycosis fungoides, intrapelvic lymph nodes
C84.07 Mycosis fungoides, spleen
C84.08 Mycosis fungoides, lymph nodes of multiple sites
C84.09 Mycosis fungoides, extranodal and solid organ sites
C84.11 Sezary disease, lymph nodes of head, face, and neck
C84.12 Sezary disease, intrathoracic lymph nodes
C84.13 Sezary disease, intra-abdominal lymph nodes
C84.14 Sezary disease, lymph nodes of axilla and upper limb
C84.15 Sezary disease, lymph nodes of inguinal region and lower limb
C84.16 Sezary disease, intrapelvic lymph nodes
C84.17 Sezary disease, spleen
C84.18 Sezary disease, lymph nodes of multiple sites
C84.19 Sezary disease, extranodal and solid organ sites
C84.41 Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck
C84.42 Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes
C84.43 Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes
C84.44 Peripheral T-cell lymphoma, not classified, lymph nodes of axilla and upper limb
C84.45 Peripheral T-cell lymphoma, not classified, lymph nodes of inguinal region and lower limb
C84.46 Peripheral T-cell lymphoma, not classified, intrapelvic lymph nodes
C84.47 Peripheral T-cell lymphoma, not classified, spleen
C84.48 Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
C84.49 Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites
C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck
C84.62 Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes
C84.63 Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes
C84.64 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb
C84.65 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb
C84.66 Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes
C84.67 Anaplastic large cell lymphoma, ALK-positive, spleen
C84.68 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites
C84.69 Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites
C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck
C84.72 Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes
C84.73 Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes
C84.74 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb
C84.75 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb
C84.76 Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes
C84.77 Anaplastic large cell lymphoma, ALK-negative, spleen
C84.78 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites
C84.79 Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites
C84.7A Anaplastic large cell lymphoma, ALK-negative, breast
C84.A1 Cutaneous T-cell lymphoma, unspecified lymph nodes of head, face, and neck
C84.A2 Cutaneous T-cell lymphoma, unspecified, intrathoracic lymph nodes
C84.A3 Cutaneous T-cell lymphoma, unspecified, intra-abdominal lymph nodes
C84.A4 Cutaneous T-cell lymphoma, unspecified, lymph nodes of axilla and upper limb
C84.A5 Cutaneous T-cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb
C84.A6 Cutaneous T-cell lymphoma, unspecified, intrapelvic lymph nodes
C84.A7 Cutaneous T-cell lymphoma, unspecified, spleen
C84.A8 Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites
C84.A9 Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites
C84.Z1 Other mature T/NK-cell lymphomas, lymph nodes of head, face, and neck
C84.Z2 Other mature T/NK-cell lymphomas, intrathoracic lymph nodes
C84.Z3 Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes
C84.Z4 Other mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb
C84.Z5 Other mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb
C84.Z6 Other mature T/NK-cell lymphomas, intrapelvic lymph nodes
C84.Z7 Other mature T/NK-cell lymphomas, spleen
C84.Z8 Other mature T/NK-cell lymphomas, lymph nodes of multiple sites
C84.Z9 Other mature T/NK-cell lymphomas, extranodal and solid organ sites
C84.91 Mature T/NK-cell lymphomas, unspecified, lymph nodes of head, face, and neck
C84.92 Mature T/NK-cell lymphomas, unspecified, intrathoracic lymph nodes
C84.93 Mature T/NK-cell lymphomas, unspecified, intra-abdominal lymph nodes
C84.94 Mature T/NK-cell lymphomas, unspecified, lymph nodes of axilla and upper limb
C84.95 Mature T/NK-cell lymphomas, unspecified, lymph nodes of inguinal region and lower limb
C84.96 Mature T/NK-cell lymphomas, unspecified, intrapelvic lymph nodes
C84.97 Mature T/NK-cell lymphomas, unspecified, spleen
C84.98 Mature T/NK-cell lymphomas, unspecified, lymph nodes of multiple sites
C84.99 Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites
C85.11 Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
C85.12 Unspecified B-cell lymphoma, intrathoracic lymph nodes
C85.13 Unspecified B-cell lymphoma, intra-abdominal lymph nodes
C85.14 Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb
C85.15 Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb
C85.16 Unspecified B-cell lymphoma, intrapelvic lymph nodes
C85.17 Unspecified B-cell lymphoma, spleen
C85.18 Unspecified B-cell lymphoma, lymph nodes of multiple sites
C85.19 Unspecified B-cell lymphoma, extranodal and solid organ sites
C85.21 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck
C85.22 Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes
C85.23 Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes
C85.24 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb
C85.25 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb
C85.26 Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes
C85.27 Mediastinal (thymic) large B-cell lymphoma, spleen
C85.28 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites
C85.29 Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites
C85.81 Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck
C85.82 Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes
C85.83 Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes
C85.84 Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb
C85.85 Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C85.86 Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes
C85.87 Other specified types of non-Hodgkin lymphoma, spleen
C85.88 Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites
C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites
C85.91 Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
C85.92 Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes
C85.93 Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes
C85.94 Non-Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb
C85.95 Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb
C85.96 Non-Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
C85.97 Non-Hodgkin lymphoma, unspecified, spleen
C85.98 Non-Hodgkin lymphoma, unspecified, lymph nodes of multiple sites
C85.99 Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C86.0 Extranodal NK/T-cell lymphoma, nasal type
C86.1 Hepatosplenic T-cell lymphoma
C86.2 Enteropathy-type (intestinal) T-cell lymphoma
C86.3 Subcutaneous panniculitis-like T-cell lymphoma
C86.4 Blastic NK-cell lymphoma
C86.5 Angioimmunoblastic T-cell lymphoma
C86.6 Primary cutaneous CD30-positive T-cell proliferations
C88.0 Waldenstrom macroglobulinemia
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C91.40 Hairy cell leukemia not having achieved remission
C91.41 Hairy cell leukemia, in remission
C91.42 Hairy cell leukemia, in relapse
C96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis
C96.21 Aggressive systemic mastocytosis
C96.22 Mast cell sarcoma
C96.29 Other malignant mast cell neoplasm
C96.4 Sarcoma of dendritic cells (accessory cells)
C96.A Histiocytic sarcoma
C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
D47.Z2 Castleman disease
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
G13.0 Paraneoplastic neuromyopathy and neuropathy
R91.1 Solitary pulmonary nodule
R91.8 Other nonspecific abnormal finding of lung field
R93.0 Abnormal findings on diagnostic imaging of skull and head, not elsewhere classified
R93.2 Abnormal findings on diagnostic imaging of liver and biliary tract
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
R93.41 Abnormal radiologic findings on diagnostic imaging of renal pelvis, ureter, or bladder
R93.421 Abnormal radiologic findings on diagnostic imaging of right kidney
R93.422 Abnormal radiologic findings on diagnostic imaging of left kidney
R93.49 Abnormal radiologic findings on diagnostic imaging of other urinary organs
R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum
R94.02 Abnormal brain scan
Z85.01 Personal history of malignant neoplasm of esophagus
Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung
Z85.118 Personal history of other malignant neoplasm of bronchus and lung
Z85.12 Personal history of malignant neoplasm of trachea
Z85.21 Personal history of malignant neoplasm of larynx
Z85.22 Personal history of malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
Z85.3 Personal history of malignant neoplasm of breast
Z85.43 Personal history of malignant neoplasm of ovary
Z85.71 Personal history of Hodgkin lymphoma
Z85.72 Personal history of non-Hodgkin lymphomas
Z85.79 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues
Z85.810 Personal history of malignant neoplasm of tongue
Z85.818 Personal history of malignant neoplasm of other sites of lip, oral cavity, and pharynx
Z85.820 Personal history of malignant melanoma of skin
Z85.828 Personal history of other malignant neoplasm of skin
Z85.830 Personal history of malignant neoplasm of bone
Z85.850 Personal history of malignant neoplasm of thyroid

Group 6

(358 Codes)
Group 6 Paragraph

List II (For CPT codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816)

The following diagnoses may be covered for initial and subsequent treatment strategy using A9552 as the tracer. When billing PET scans used for initial strategy, use “PI” modifier, if subsequent strategy with these diagnoses use the modifier "PS" on the claim.

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.

Group 6 Codes
CodeDescription
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6 Malignant neoplasm of greater curvature of stomach, unspecified
C16.8 Malignant neoplasm of overlapping sites of stomach
C17.0 Malignant neoplasm of duodenum
C17.1 Malignant neoplasm of jejunum
C17.2 Malignant neoplasm of ileum
C17.3 Meckel's diverticulum, malignant
C17.8 Malignant neoplasm of overlapping sites of small intestine
C21.1 Malignant neoplasm of anal canal
C22.0 Liver cell carcinoma
C22.1 Intrahepatic bile duct carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C23 Malignant neoplasm of gallbladder
C24.0 Malignant neoplasm of extrahepatic bile duct
C24.1 Malignant neoplasm of ampulla of Vater
C24.8 Malignant neoplasm of overlapping sites of biliary tract
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C26.1 Malignant neoplasm of spleen
C37 Malignant neoplasm of thymus
C38.0 Malignant neoplasm of heart
C38.1 Malignant neoplasm of anterior mediastinum
C38.2 Malignant neoplasm of posterior mediastinum
C38.4 Malignant neoplasm of pleura
C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
C40.01 Malignant neoplasm of scapula and long bones of right upper limb
C40.02 Malignant neoplasm of scapula and long bones of left upper limb
C40.11 Malignant neoplasm of short bones of right upper limb
C40.12 Malignant neoplasm of short bones of left upper limb
C40.21 Malignant neoplasm of long bones of right lower limb
C40.22 Malignant neoplasm of long bones of left lower limb
C40.31 Malignant neoplasm of short bones of right lower limb
C40.32 Malignant neoplasm of short bones of left lower limb
C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb
C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
C40.91 Malignant neoplasm of unspecified bones and articular cartilage of right limb
C40.92 Malignant neoplasm of unspecified bones and articular cartilage of left limb
C41.0 Malignant neoplasm of bones of skull and face
C41.1 Malignant neoplasm of mandible
C41.2 Malignant neoplasm of vertebral column
C41.3 Malignant neoplasm of ribs, sternum and clavicle
C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx
C41.9 Malignant neoplasm of bone and articular cartilage, unspecified
C4A.0 Merkel cell carcinoma of lip
C4A.111 Merkel cell carcinoma of right upper eyelid, including canthus
C4A.112 Merkel cell carcinoma of right lower eyelid, including canthus
C4A.121 Merkel cell carcinoma of left upper eyelid, including canthus
C4A.122 Merkel cell carcinoma of left lower eyelid, including canthus
C4A.21 Merkel cell carcinoma of right ear and external auricular canal
C4A.22 Merkel cell carcinoma of left ear and external auricular canal
C4A.31 Merkel cell carcinoma of nose
C4A.39 Merkel cell carcinoma of other parts of face
C4A.4 Merkel cell carcinoma of scalp and neck
C4A.51 Merkel cell carcinoma of anal skin
C4A.52 Merkel cell carcinoma of skin of breast
C4A.59 Merkel cell carcinoma of other part of trunk
C4A.61 Merkel cell carcinoma of right upper limb, including shoulder
C4A.62 Merkel cell carcinoma of left upper limb, including shoulder
C4A.71 Merkel cell carcinoma of right lower limb, including hip
C4A.72 Merkel cell carcinoma of left lower limb, including hip
C4A.8 Merkel cell carcinoma of overlapping sites
C44.500 Unspecified malignant neoplasm of anal skin
C44.501 Unspecified malignant neoplasm of skin of breast
C44.510 Basal cell carcinoma of anal skin
C44.511 Basal cell carcinoma of skin of breast
C44.519 Basal cell carcinoma of skin of other part of trunk
C44.520 Squamous cell carcinoma of anal skin
C44.521 Squamous cell carcinoma of skin of breast
C44.529 Squamous cell carcinoma of skin of other part of trunk
C44.590 Other specified malignant neoplasm of anal skin
C44.591 Other specified malignant neoplasm of skin of breast
C44.599 Other specified malignant neoplasm of skin of other part of trunk
C44.602 Unspecified malignant neoplasm of skin of right upper limb, including shoulder
C44.609 Unspecified malignant neoplasm of skin of left upper limb, including shoulder
C44.612 Basal cell carcinoma of skin of right upper limb, including shoulder
C44.619 Basal cell carcinoma of skin of left upper limb, including shoulder
C44.622 Squamous cell carcinoma of skin of right upper limb, including shoulder
C44.629 Squamous cell carcinoma of skin of left upper limb, including shoulder
C44.692 Other specified malignant neoplasm of skin of right upper limb, including shoulder
C44.699 Other specified malignant neoplasm of skin of left upper limb, including shoulder
C44.702 Unspecified malignant neoplasm of skin of right lower limb, including hip
C44.709 Unspecified malignant neoplasm of skin of left lower limb, including hip
C44.722 Squamous cell carcinoma of skin of right lower limb, including hip
C44.729 Squamous cell carcinoma of skin of left lower limb, including hip
C44.792 Other specified malignant neoplasm of skin of right lower limb, including hip
C44.799 Other specified malignant neoplasm of skin of left lower limb, including hip
C44.80 Unspecified malignant neoplasm of overlapping sites of skin
C44.81 Basal cell carcinoma of overlapping sites of skin
C44.82 Squamous cell carcinoma of overlapping sites of skin
C44.89 Other specified malignant neoplasm of overlapping sites of skin
C45.0 Mesothelioma of pleura
C45.1 Mesothelioma of peritoneum
C45.2 Mesothelioma of pericardium
C45.7 Mesothelioma of other sites
C46.0 Kaposi's sarcoma of skin
C46.1 Kaposi's sarcoma of soft tissue
C46.2 Kaposi's sarcoma of palate
C46.3 Kaposi's sarcoma of lymph nodes
C46.4 Kaposi's sarcoma of gastrointestinal sites
C46.51 Kaposi's sarcoma of right lung
C46.52 Kaposi's sarcoma of left lung
C46.7 Kaposi's sarcoma of other sites
C47.11 Malignant neoplasm of peripheral nerves of right upper limb, including shoulder
C47.12 Malignant neoplasm of peripheral nerves of left upper limb, including shoulder
C47.21 Malignant neoplasm of peripheral nerves of right lower limb, including hip
C47.22 Malignant neoplasm of peripheral nerves of left lower limb, including hip
C47.3 Malignant neoplasm of peripheral nerves of thorax
C47.4 Malignant neoplasm of peripheral nerves of abdomen
C47.5 Malignant neoplasm of peripheral nerves of pelvis
C47.8 Malignant neoplasm of overlapping sites of peripheral nerves and autonomic nervous system
C48.0 Malignant neoplasm of retroperitoneum
C48.1 Malignant neoplasm of specified parts of peritoneum
C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C49.11 Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder
C49.12 Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder
C49.21 Malignant neoplasm of connective and soft tissue of right lower limb, including hip
C49.22 Malignant neoplasm of connective and soft tissue of left lower limb, including hip
C49.3 Malignant neoplasm of connective and soft tissue of thorax
C49.4 Malignant neoplasm of connective and soft tissue of abdomen
C49.5 Malignant neoplasm of connective and soft tissue of pelvis
C49.8 Malignant neoplasm of overlapping sites of connective and soft tissue
C49.A1 Gastrointestinal stromal tumor of esophagus
C49.A2 Gastrointestinal stromal tumor of stomach
C49.A3 Gastrointestinal stromal tumor of small intestine
C49.A4 Gastrointestinal stromal tumor of large intestine
C49.A5 Gastrointestinal stromal tumor of rectum
C49.A9 Gastrointestinal stromal tumor of other sites
C51.0 Malignant neoplasm of labium majus
C51.1 Malignant neoplasm of labium minus
C51.2 Malignant neoplasm of clitoris
C51.8 Malignant neoplasm of overlapping sites of vulva
C52 Malignant neoplasm of vagina
C54.0 Malignant neoplasm of isthmus uteri
C54.1 Malignant neoplasm of endometrium
C54.2 Malignant neoplasm of myometrium
C54.3 Malignant neoplasm of fundus uteri
C54.8 Malignant neoplasm of overlapping sites of corpus uteri
C57.01 Malignant neoplasm of right fallopian tube
C57.02 Malignant neoplasm of left fallopian tube
C57.11 Malignant neoplasm of right broad ligament
C57.12 Malignant neoplasm of left broad ligament
C57.21 Malignant neoplasm of right round ligament
C57.22 Malignant neoplasm of left round ligament
C57.3 Malignant neoplasm of parametrium
C57.4 Malignant neoplasm of uterine adnexa, unspecified
C57.7 Malignant neoplasm of other specified female genital organs
C57.8 Malignant neoplasm of overlapping sites of female genital organs
C58 Malignant neoplasm of placenta
C60.0 Malignant neoplasm of prepuce
C60.1 Malignant neoplasm of glans penis
C60.2 Malignant neoplasm of body of penis
C60.8 Malignant neoplasm of overlapping sites of penis
C62.01 Malignant neoplasm of undescended right testis
C62.02 Malignant neoplasm of undescended left testis
C62.11 Malignant neoplasm of descended right testis
C62.12 Malignant neoplasm of descended left testis
C63.01 Malignant neoplasm of right epididymis
C63.02 Malignant neoplasm of left epididymis
C63.11 Malignant neoplasm of right spermatic cord
C63.12 Malignant neoplasm of left spermatic cord
C63.2 Malignant neoplasm of scrotum
C63.7 Malignant neoplasm of other specified male genital organs
C63.8 Malignant neoplasm of overlapping sites of male genital organs
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C66.1 Malignant neoplasm of right ureter
C66.2 Malignant neoplasm of left ureter
C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.7 Malignant neoplasm of urachus
C67.8 Malignant neoplasm of overlapping sites of bladder
C68.0 Malignant neoplasm of urethra
C68.1 Malignant neoplasm of paraurethral glands
C68.8 Malignant neoplasm of overlapping sites of urinary organs
C69.01 Malignant neoplasm of right conjunctiva
C69.02 Malignant neoplasm of left conjunctiva
C69.11 Malignant neoplasm of right cornea
C69.12 Malignant neoplasm of left cornea
C69.21 Malignant neoplasm of right retina
C69.22 Malignant neoplasm of left retina
C69.31 Malignant neoplasm of right choroid
C69.32 Malignant neoplasm of left choroid
C69.41 Malignant neoplasm of right ciliary body
C69.42 Malignant neoplasm of left ciliary body
C69.51 Malignant neoplasm of right lacrimal gland and duct
C69.52 Malignant neoplasm of left lacrimal gland and duct
C69.61 Malignant neoplasm of right orbit
C69.62 Malignant neoplasm of left orbit
C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa
C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa
C70.0 Malignant neoplasm of cerebral meninges
C70.1 Malignant neoplasm of spinal meninges
C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles
C71.1 Malignant neoplasm of frontal lobe
C71.2 Malignant neoplasm of temporal lobe
C71.3 Malignant neoplasm of parietal lobe
C71.4 Malignant neoplasm of occipital lobe
C71.5 Malignant neoplasm of cerebral ventricle
C71.6 Malignant neoplasm of cerebellum
C71.7 Malignant neoplasm of brain stem
C71.8 Malignant neoplasm of overlapping sites of brain
C72.0 Malignant neoplasm of spinal cord
C72.1 Malignant neoplasm of cauda equina
C72.21 Malignant neoplasm of right olfactory nerve
C72.22 Malignant neoplasm of left olfactory nerve
C72.31 Malignant neoplasm of right optic nerve
C72.32 Malignant neoplasm of left optic nerve
C72.41 Malignant neoplasm of right acoustic nerve
C72.42 Malignant neoplasm of left acoustic nerve
C72.59 Malignant neoplasm of other cranial nerves
C74.01 Malignant neoplasm of cortex of right adrenal gland
C74.02 Malignant neoplasm of cortex of left adrenal gland
C74.11 Malignant neoplasm of medulla of right adrenal gland
C74.12 Malignant neoplasm of medulla of left adrenal gland
C74.91 Malignant neoplasm of unspecified part of right adrenal gland
C74.92 Malignant neoplasm of unspecified part of left adrenal gland
C75.0 Malignant neoplasm of parathyroid gland
C75.1 Malignant neoplasm of pituitary gland
C75.2 Malignant neoplasm of craniopharyngeal duct
C75.3 Malignant neoplasm of pineal gland
C75.5 Malignant neoplasm of aortic body and other paraganglia
C75.8 Malignant neoplasm with pluriglandular involvement, unspecified
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.019 Malignant carcinoid tumor of the small intestine, unspecified portion
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.029 Malignant carcinoid tumor of the large intestine, unspecified portion
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.098 Malignant carcinoid tumors of other sites
C7A.1 Malignant poorly differentiated neuroendocrine tumors
C7A.8 Other malignant neuroendocrine tumors
C7B.01 Secondary carcinoid tumors of distant lymph nodes
C7B.02 Secondary carcinoid tumors of liver
C7B.03 Secondary carcinoid tumors of bone
C7B.04 Secondary carcinoid tumors of peritoneum
C7B.09 Secondary carcinoid tumors of other sites
C7B.1 Secondary Merkel cell carcinoma
C7B.8 Other secondary neuroendocrine tumors
C76.1 Malignant neoplasm of thorax
C76.2 Malignant neoplasm of abdomen
C76.3 Malignant neoplasm of pelvis
C76.41 Malignant neoplasm of right upper limb
C76.42 Malignant neoplasm of left upper limb
C76.51 Malignant neoplasm of right lower limb
C76.52 Malignant neoplasm of left lower limb
C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C77.1 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
C77.3 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
C77.4 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes
C77.5 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.1 Secondary malignant neoplasm of mediastinum
C78.2 Secondary malignant neoplasm of pleura
C78.39 Secondary malignant neoplasm of other respiratory organs
C78.4 Secondary malignant neoplasm of small intestine
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C78.89 Secondary malignant neoplasm of other digestive organs
C79.01 Secondary malignant neoplasm of right kidney and renal pelvis
C79.02 Secondary malignant neoplasm of left kidney and renal pelvis
C79.11 Secondary malignant neoplasm of bladder
C79.19 Secondary malignant neoplasm of other urinary organs
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.32 Secondary malignant neoplasm of cerebral meninges
C79.49 Secondary malignant neoplasm of other parts of nervous system
C79.51 Secondary malignant neoplasm of bone
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.63 Secondary malignant neoplasm of bilateral ovaries
C79.71 Secondary malignant neoplasm of right adrenal gland
C79.72 Secondary malignant neoplasm of left adrenal gland
C79.81 Secondary malignant neoplasm of breast
C79.82 Secondary malignant neoplasm of genital organs
C79.89 Secondary malignant neoplasm of other specified sites
C80.2 Malignant neoplasm associated with transplanted organ
G13.0 Paraneoplastic neuromyopathy and neuropathy
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
R93.41 Abnormal radiologic findings on diagnostic imaging of renal pelvis, ureter, or bladder
R93.421 Abnormal radiologic findings on diagnostic imaging of right kidney
R93.422 Abnormal radiologic findings on diagnostic imaging of left kidney
R93.49 Abnormal radiologic findings on diagnostic imaging of other urinary organs
R94.02 Abnormal brain scan
Z85.020 Personal history of malignant carcinoid tumor of stomach
Z85.028 Personal history of other malignant neoplasm of stomach
Z85.030 Personal history of malignant carcinoid tumor of large intestine
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.040 Personal history of malignant carcinoid tumor of rectum
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.05 Personal history of malignant neoplasm of liver
Z85.060 Personal history of malignant carcinoid tumor of small intestine
Z85.068 Personal history of other malignant neoplasm of small intestine
Z85.07 Personal history of malignant neoplasm of pancreas
Z85.09 Personal history of malignant neoplasm of other digestive organs
Z85.230 Personal history of malignant carcinoid tumor of thymus
Z85.238 Personal history of other malignant neoplasm of thymus
Z85.29 Personal history of malignant neoplasm of other respiratory and intrathoracic organs
Z85.40 Personal history of malignant neoplasm of unspecified female genital organ
Z85.41 Personal history of malignant neoplasm of cervix uteri
Z85.42 Personal history of malignant neoplasm of other parts of uterus
Z85.43 Personal history of malignant neoplasm of ovary
Z85.44 Personal history of malignant neoplasm of other female genital organs
Z85.47 Personal history of malignant neoplasm of testis
Z85.48 Personal history of malignant neoplasm of epididymis
Z85.49 Personal history of malignant neoplasm of other male genital organs
Z85.51 Personal history of malignant neoplasm of bladder
Z85.520 Personal history of malignant carcinoid tumor of kidney
Z85.528 Personal history of other malignant neoplasm of kidney
Z85.53 Personal history of malignant neoplasm of renal pelvis
Z85.54 Personal history of malignant neoplasm of ureter
Z85.59 Personal history of malignant neoplasm of other urinary tract organ
Z85.818 Personal history of malignant neoplasm of other sites of lip, oral cavity, and pharynx
Z85.821 Personal history of Merkel cell carcinoma
Z85.830 Personal history of malignant neoplasm of bone
Z85.831 Personal history of malignant neoplasm of soft tissue
Z85.840 Personal history of malignant neoplasm of eye
Z85.841 Personal history of malignant neoplasm of brain
Z85.848 Personal history of malignant neoplasm of other parts of nervous tissue
Z85.850 Personal history of malignant neoplasm of thyroid
Z85.858 Personal history of malignant neoplasm of other endocrine glands
Z85.89 Personal history of malignant neoplasm of other organs and systems

Group 7

(115 Codes)
Group 7 Paragraph

List III (For CPT codes 78811, 78812, 78813, 78814, 78815, or 78816)

The following diagnoses may be coverable for initial or subsequent treatment strategies using A9552 as the tracer. When PET scan is used for initial or subsequent strategies with these diagnoses, the modifiers “PI” or “PS” must appear on the claims.

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.

Group 7 Codes
CodeDescription
C88.0 Waldenstrom macroglobulinemia
C88.2 Heavy chain disease
C88.3 Immunoproliferative small intestinal disease
C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]
C88.8 Other malignant immunoproliferative diseases
C88.9 Malignant immunoproliferative disease, unspecified
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C90.10 Plasma cell leukemia not having achieved remission
C90.11 Plasma cell leukemia in remission
C90.12 Plasma cell leukemia in relapse
C90.20 Extramedullary plasmacytoma not having achieved remission
C90.21 Extramedullary plasmacytoma in remission
C90.22 Extramedullary plasmacytoma in relapse
C90.30 Solitary plasmacytoma not having achieved remission
C90.31 Solitary plasmacytoma in remission
C90.32 Solitary plasmacytoma in relapse
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission
C91.11 Chronic lymphocytic leukemia of B-cell type in remission
C91.12 Chronic lymphocytic leukemia of B-cell type in relapse
C91.30 Prolymphocytic leukemia of B-cell type not having achieved remission
C91.31 Prolymphocytic leukemia of B-cell type, in remission
C91.32 Prolymphocytic leukemia of B-cell type, in relapse
C91.50 Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission
C91.51 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission
C91.52 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse
C91.60 Prolymphocytic leukemia of T-cell type not having achieved remission
C91.61 Prolymphocytic leukemia of T-cell type, in remission
C91.62 Prolymphocytic leukemia of T-cell type, in relapse
C91.A0 Mature B-cell leukemia Burkitt-type not having achieved remission
C91.A1 Mature B-cell leukemia Burkitt-type, in remission
C91.A2 Mature B-cell leukemia Burkitt-type, in relapse
C91.Z0 Other lymphoid leukemia not having achieved remission
C91.Z1 Other lymphoid leukemia, in remission
C91.Z2 Other lymphoid leukemia, in relapse
C91.90 Lymphoid leukemia, unspecified not having achieved remission
C91.91 Lymphoid leukemia, unspecified, in remission
C91.92 Lymphoid leukemia, unspecified, in relapse
C92.00 Acute myeloblastic leukemia, not having achieved remission
C92.01 Acute myeloblastic leukemia, in remission
C92.02 Acute myeloblastic leukemia, in relapse
C92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.11 Chronic myeloid leukemia, BCR/ABL-positive, in remission
C92.12 Chronic myeloid leukemia, BCR/ABL-positive, in relapse
C92.20 Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission
C92.21 Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission
C92.22 Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse
C92.30 Myeloid sarcoma, not having achieved remission
C92.31 Myeloid sarcoma, in remission
C92.32 Myeloid sarcoma, in relapse
C92.40 Acute promyelocytic leukemia, not having achieved remission
C92.41 Acute promyelocytic leukemia, in remission
C92.42 Acute promyelocytic leukemia, in relapse
C92.50 Acute myelomonocytic leukemia, not having achieved remission
C92.51 Acute myelomonocytic leukemia, in remission
C92.52 Acute myelomonocytic leukemia, in relapse
C92.60 Acute myeloid leukemia with 11q23-abnormality not having achieved remission
C92.61 Acute myeloid leukemia with 11q23-abnormality in remission
C92.62 Acute myeloid leukemia with 11q23-abnormality in relapse
C92.A0 Acute myeloid leukemia with multilineage dysplasia, not having achieved remission
C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission
C92.A2 Acute myeloid leukemia with multilineage dysplasia, in relapse
C92.Z0 Other myeloid leukemia not having achieved remission
C92.Z1 Other myeloid leukemia, in remission
C92.Z2 Other myeloid leukemia, in relapse
C92.90 Myeloid leukemia, unspecified, not having achieved remission
C92.91 Myeloid leukemia, unspecified in remission
C92.92 Myeloid leukemia, unspecified in relapse
C93.00 Acute monoblastic/monocytic leukemia, not having achieved remission
C93.01 Acute monoblastic/monocytic leukemia, in remission
C93.02 Acute monoblastic/monocytic leukemia, in relapse
C93.10 Chronic myelomonocytic leukemia not having achieved remission
C93.11 Chronic myelomonocytic leukemia, in remission
C93.12 Chronic myelomonocytic leukemia, in relapse
C93.30 Juvenile myelomonocytic leukemia, not having achieved remission
C93.31 Juvenile myelomonocytic leukemia, in remission
C93.32 Juvenile myelomonocytic leukemia, in relapse
C93.Z0 Other monocytic leukemia, not having achieved remission
C93.Z1 Other monocytic leukemia, in remission
C93.Z2 Other monocytic leukemia, in relapse
C93.90 Monocytic leukemia, unspecified, not having achieved remission
C93.91 Monocytic leukemia, unspecified in remission
C93.92 Monocytic leukemia, unspecified in relapse
C94.00 Acute erythroid leukemia, not having achieved remission
C94.01 Acute erythroid leukemia, in remission
C94.02 Acute erythroid leukemia, in relapse
C94.20 Acute megakaryoblastic leukemia not having achieved remission
C94.21 Acute megakaryoblastic leukemia, in remission
C94.22 Acute megakaryoblastic leukemia, in relapse
C94.30 Mast cell leukemia not having achieved remission
C94.31 Mast cell leukemia, in remission
C94.32 Mast cell leukemia, in relapse
C94.40 Acute panmyelosis with myelofibrosis not having achieved remission
C94.41 Acute panmyelosis with myelofibrosis, in remission
C94.42 Acute panmyelosis with myelofibrosis, in relapse
C94.80 Other specified leukemias not having achieved remission
C94.81 Other specified leukemias, in remission
C94.82 Other specified leukemias, in relapse
C95.00 Acute leukemia of unspecified cell type not having achieved remission
C95.01 Acute leukemia of unspecified cell type, in remission
C95.02 Acute leukemia of unspecified cell type, in relapse
C95.10 Chronic leukemia of unspecified cell type not having achieved remission
C95.11 Chronic leukemia of unspecified cell type, in remission
C95.12 Chronic leukemia of unspecified cell type, in relapse
C95.90 Leukemia, unspecified not having achieved remission
C95.91 Leukemia, unspecified, in remission
C95.92 Leukemia, unspecified, in relapse
D45 Polycythemia vera
G13.0 Paraneoplastic neuromyopathy and neuropathy
R77.9 Abnormality of plasma protein, unspecified
Z85.6 Personal history of leukemia

Group 8

(65 Codes)
Group 8 Paragraph

List IV (For CPT codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816)

The following diagnoses may be coverable for initial treatment strategy only using A9552 as the tracer. (When final diagnosis is benign, documentation must support original concern for possible malignancy.) When PET scan is used for initial strategy, use the “PI” modifier.

Note: The codes below may only be used when, at the time of billing, documentation supports concern for possible malignancy and the final interpretation of the PET indicates benign tumor.

Group 8 Codes
CodeDescription
D37.01 Neoplasm of uncertain behavior of lip
D37.02 Neoplasm of uncertain behavior of tongue
D37.030 Neoplasm of uncertain behavior of the parotid salivary glands
D37.031 Neoplasm of uncertain behavior of the sublingual salivary glands
D37.032 Neoplasm of uncertain behavior of the submandibular salivary glands
D37.04 Neoplasm of uncertain behavior of the minor salivary glands
D37.05 Neoplasm of uncertain behavior of pharynx
D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity
D37.1 Neoplasm of uncertain behavior of stomach
D37.2 Neoplasm of uncertain behavior of small intestine
D37.3 Neoplasm of uncertain behavior of appendix
D37.4 Neoplasm of uncertain behavior of colon
D37.5 Neoplasm of uncertain behavior of rectum
D37.6 Neoplasm of uncertain behavior of liver, gallbladder and bile ducts
D37.8 Neoplasm of uncertain behavior of other specified digestive organs
D38.0 Neoplasm of uncertain behavior of larynx
D38.1 Neoplasm of uncertain behavior of trachea, bronchus and lung
D38.2 Neoplasm of uncertain behavior of pleura
D38.3 Neoplasm of uncertain behavior of mediastinum
D38.4 Neoplasm of uncertain behavior of thymus
D38.5 Neoplasm of uncertain behavior of other respiratory organs
D39.0 Neoplasm of uncertain behavior of uterus
D39.11 Neoplasm of uncertain behavior of right ovary
D39.12 Neoplasm of uncertain behavior of left ovary
D39.2 Neoplasm of uncertain behavior of placenta
D39.8 Neoplasm of uncertain behavior of other specified female genital organs
D40.0 Neoplasm of uncertain behavior of prostate
D40.11 Neoplasm of uncertain behavior of right testis
D40.12 Neoplasm of uncertain behavior of left testis
D40.8 Neoplasm of uncertain behavior of other specified male genital organs
D41.01 Neoplasm of uncertain behavior of right kidney
D41.02 Neoplasm of uncertain behavior of left kidney
D41.11 Neoplasm of uncertain behavior of right renal pelvis
D41.12 Neoplasm of uncertain behavior of left renal pelvis
D41.21 Neoplasm of uncertain behavior of right ureter
D41.22 Neoplasm of uncertain behavior of left ureter
D41.3 Neoplasm of uncertain behavior of urethra
D41.4 Neoplasm of uncertain behavior of bladder
D41.8 Neoplasm of uncertain behavior of other specified urinary organs
D42.0 Neoplasm of uncertain behavior of cerebral meninges
D42.1 Neoplasm of uncertain behavior of spinal meninges
D43.0 Neoplasm of uncertain behavior of brain, supratentorial
D43.1 Neoplasm of uncertain behavior of brain, infratentorial
D43.3 Neoplasm of uncertain behavior of cranial nerves
D43.4 Neoplasm of uncertain behavior of spinal cord
D43.8 Neoplasm of uncertain behavior of other specified parts of central nervous system
D44.0 Neoplasm of uncertain behavior of thyroid gland
D44.11 Neoplasm of uncertain behavior of right adrenal gland
D44.12 Neoplasm of uncertain behavior of left adrenal gland
D44.2 Neoplasm of uncertain behavior of parathyroid gland
D44.3 Neoplasm of uncertain behavior of pituitary gland
D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct
D44.5 Neoplasm of uncertain behavior of pineal gland
D44.6 Neoplasm of uncertain behavior of carotid body
D44.7 Neoplasm of uncertain behavior of aortic body and other paraganglia
D48.0 Neoplasm of uncertain behavior of bone and articular cartilage
D48.1 Neoplasm of uncertain behavior of connective and other soft tissue
D48.2 Neoplasm of uncertain behavior of peripheral nerves and autonomic nervous system
D48.3 Neoplasm of uncertain behavior of retroperitoneum
D48.4 Neoplasm of uncertain behavior of peritoneum
D48.5 Neoplasm of uncertain behavior of skin
D48.61 Neoplasm of uncertain behavior of right breast
D48.62 Neoplasm of uncertain behavior of left breast
D48.7 Neoplasm of uncertain behavior of other specified sites
G13.0 Paraneoplastic neuromyopathy and neuropathy

Group 9

(1 Code)
Group 9 Paragraph

List V (For CPT codes 78811, 78812, 78813, 78814, 78815, or 78816)

The following diagnoses may be coverable for initial treatment strategy only using A9552 as the tracer. When PET scan is used for initial strategy, use the “PI” modifier.

Group 9 Codes
CodeDescription
D47.Z1 Post-transplant lymphoproliferative disorder (PTLD)

Group 10

(4 Codes)
Group 10 Paragraph

List VI (For CPT codes 78811, 78812, 78813, 78814, 78815, or 78816)

Prostate CA is its own list and may be covered for subsequent strategy only using A9552 as the tracer. When PET scan is used for subsequent strategy, use the "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.

Group 10 Codes
CodeDescription
C61 Malignant neoplasm of prostate
G13.0 Paraneoplastic neuromyopathy and neuropathy
R97.21 Rising PSA following treatment for malignant neoplasm of prostate
Z85.46 Personal history of malignant neoplasm of prostate

Group 11

(3 Codes)
Group 11 Paragraph

Per CR 8381, effective for dates of service on or after March 7, 2013, CMS has determined that, unless there is a specific NCD to the contrary, local Medicare Administrative Contractors (MACs) may determine coverage (or non-coverage) within their respective jurisdictions for PET using new, proprietary radiopharmaceuticals for their FDA-approved labeled indications for oncologic imaging only.

Contractor Determined Coverage for FDA Labeled Indications of Proprietary Radiopharmaceuticals:

  • Choline C11, diagnostic, per study dose, effective 03/07/2013
  • Gallium 68 Dotatate injection, effective 09/15/2016
  • Fluciclovine F18 injection, effective 10/01/2016
  • Fluoroestradiol f 18, effective 01/01/2021
  • Copper Cu64 Dotatate, effective 01/01/2021
  • Gallium ga-68 psma-11 (UCSF), effective 07/01/2021
  • Gallium ga-68 psma-11 (UCLA), effective 07/01/2021
  • piflufolastat F 18 (PYLARIFY®), effective 05/26/2021
  • Gallium 68-ga Gozetotide/PSMA-11 (Illuccix®), effective 12/17/2021

Note: Not all of the above tracers have OPPS pass thru status and will be denied as packaged. Only the tracers that do have pass thru status will be noted in each specified group of DX codes below.

The following diagnoses are applicable to A9515 when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use the 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.

Group 11 Codes
CodeDescription
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

Group 12

(29 Codes)
Group 12 Paragraph

The following diagnoses are applicable to Gallium 68 Dotatate injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9587 to bill for this service per CR 9861, effective 1/1/2017. Use the PI or PS modifier.

Group 12 Codes
CodeDescription
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.019 Malignant carcinoid tumor of the small intestine, unspecified portion
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.029 Malignant carcinoid tumor of the large intestine, unspecified portion
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.098 Malignant carcinoid tumors of other sites
C7A.1 Malignant poorly differentiated neuroendocrine tumors
C7A.8 Other malignant neuroendocrine tumors
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.1 Secondary malignant neoplasm of mediastinum
C78.2 Secondary malignant neoplasm of pleura
C78.39 Secondary malignant neoplasm of other respiratory organs
C78.4 Secondary malignant neoplasm of small intestine
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C78.89 Secondary malignant neoplasm of other digestive organs

Group 13

(3 Codes)
Group 13 Paragraph

The following diagnoses are applicable to Fluciclovine F18 injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9588 to bill for this service per CR 9861, effective 1/1/2017. Use the 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.

Group 13 Codes
CodeDescription
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

Group 14

(34 Codes)
Group 14 Paragraph

The following diagnoses are applicable to Fluoroestradiol f18 injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9591 to bill for this service per CR 11907, effective 1/1/2021. Use the PS modifier.

When A9591 is billed in the OPPS setting or in Part B outpatient setting, the diagnosis codes below will be paid,

NOTE: Whenever the personal history diagnosis code Z85.3 is on the claim, it MUST be billed with one of the C50.XXX diagnosis codes or C79.81 below.

Group 14 Codes
CodeDescription
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C79.81 Secondary malignant neoplasm of breast
Z85.3 Personal history of malignant neoplasm of breast

Group 15

(32 Codes)
Group 15 Paragraph

The following diagnoses are applicable to A9592 for Copper Cu64 Dotatate injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9592 to bill for this service per CR 12029, effective 4/1/2021. Use the PI or PS modifier.

When A9592 is billed in the OPPS setting or in Part B outpatient setting, the diagnosis codes below will be paid, effective 04/01/2021.

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.

Group 15 Codes
CodeDescription
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.094 Malignant carcinoid tumor of the foregut, unspecified
C7A.095 Malignant carcinoid tumor of the midgut, unspecified
C7A.096 Malignant carcinoid tumor of the hindgut, unspecified
C7A.098 Malignant carcinoid tumors of other sites
C7A.1 Malignant poorly differentiated neuroendocrine tumors
C7A.8 Other malignant neuroendocrine tumors
C7B.01 Secondary carcinoid tumors of distant lymph nodes
C7B.02 Secondary carcinoid tumors of liver
C7B.03 Secondary carcinoid tumors of bone
C7B.04 Secondary carcinoid tumors of peritoneum
C7B.09 Secondary carcinoid tumors of other sites
Z85.020 Personal history of malignant carcinoid tumor of stomach
Z85.030 Personal history of malignant carcinoid tumor of large intestine
Z85.040 Personal history of malignant carcinoid tumor of rectum
Z85.060 Personal history of malignant carcinoid tumor of small intestine
Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung
Z85.230 Personal history of malignant carcinoid tumor of thymus
Z85.520 Personal history of malignant carcinoid tumor of kidney

Group 16

(3 Codes)
Group 16 Paragraph

The following diagnoses are applicable to Gallium ga-68 psma-11 (UCSF) and Gallium ga-68 psma-11 (UCLA) injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9593 for the UCSF OR A9594 for the UCLA formulation to bill for this service per CR 12142 effective 7/1/2021. Use the PS modifier.

When A9593 or A9594 is billed in the OPPS setting or in Part B outpatient setting, the diagnosis codes below will be paid, effective 07/01/2021.

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.

Effective 09/10/2021, the NCCN Guidelines have been updated to allow PSMA-PET/CT or PSMA-PET/MRI with Ga-68 PSMA-11 to be considered effective for initial staging of bone and soft tissues imaging with the use of the ‘PI’ modifier, or with suspected recurrence based on elevated serum prostate­specific antigen (PSA) level, Providers must amend the KX modifier on the claim to attest that the use of the PI modifier is per NCCN Guidelines.

 

Group 16 Codes
CodeDescription
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

Group 17

(3 Codes)
Group 17 Paragraph

The following diagnoses are applicable to piflufolastat F 18 (PYLARIFY®) injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9595 to bill for this service effective 01/01/2022. Use the PS modifier. For providers to be paid appropriately, A9595 must be billed per mCi effective 01/01/2022.

When A9595 is billed in the OPPS setting or in Part B outpatient setting, the diagnosis codes below will be paid, effective 01/01/2022.

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.

Effective 09/10/2021, the NCCN Guidelines have been updated to allow PSMA-PET/CT or PSMA-PET/MRI with piflufolastat PSMA to be considered effective for initial staging of bone and soft tissues imaging with the use of the ‘PI’ modifier, or with suspected recurrence based on elevated serum prostate­specific antigen (PSA. Providers must amend the KX modifier on the claim to attest that the use of the PI modifier is per NCCN Guidelines.

Group 17 Codes
CodeDescription
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

Group 18

(77 Codes)
Group 18 Paragraph

In addition to the noted NCD related indications for PET scans of the brain heart and cancer, Noridian has determined coverage for the now non-NCD related treatment of Inflammation and Infection effective for DOS on or after 01/01/2021. The following diagnosis codes apply to A9552 (FLUORODEOXYGLUCOSE F-18 FDG) when billed with 78608, 78811, 78812, 78813, 78814, 78815, or 78816.

 

Group 18 Codes
CodeDescription
M86.311 Chronic multifocal osteomyelitis, right shoulder
M86.312 Chronic multifocal osteomyelitis, left shoulder
M86.321 Chronic multifocal osteomyelitis, right humerus
M86.322 Chronic multifocal osteomyelitis, left humerus
M86.331 Chronic multifocal osteomyelitis, right radius and ulna
M86.332 Chronic multifocal osteomyelitis, left radius and ulna
M86.341 Chronic multifocal osteomyelitis, right hand
M86.342 Chronic multifocal osteomyelitis, left hand
M86.351 Chronic multifocal osteomyelitis, right femur
M86.352 Chronic multifocal osteomyelitis, left femur
M86.361 Chronic multifocal osteomyelitis, right tibia and fibula
M86.362 Chronic multifocal osteomyelitis, left tibia and fibula
M86.371 Chronic multifocal osteomyelitis, right ankle and foot
M86.372 Chronic multifocal osteomyelitis, left ankle and foot
M86.38 Chronic multifocal osteomyelitis, other site
M86.39 Chronic multifocal osteomyelitis, multiple sites
M86.411 Chronic osteomyelitis with draining sinus, right shoulder
M86.412 Chronic osteomyelitis with draining sinus, left shoulder
M86.421 Chronic osteomyelitis with draining sinus, right humerus
M86.422 Chronic osteomyelitis with draining sinus, left humerus
M86.431 Chronic osteomyelitis with draining sinus, right radius and ulna
M86.432 Chronic osteomyelitis with draining sinus, left radius and ulna
M86.441 Chronic osteomyelitis with draining sinus, right hand
M86.442 Chronic osteomyelitis with draining sinus, left hand
M86.451 Chronic osteomyelitis with draining sinus, right femur
M86.452 Chronic osteomyelitis with draining sinus, left femur
M86.461 Chronic osteomyelitis with draining sinus, right tibia and fibula
M86.462 Chronic osteomyelitis with draining sinus, left tibia and fibula
M86.471 Chronic osteomyelitis with draining sinus, right ankle and foot
M86.472 Chronic osteomyelitis with draining sinus, left ankle and foot
M86.48 Chronic osteomyelitis with draining sinus, other site
M86.49 Chronic osteomyelitis with draining sinus, multiple sites
M86.511 Other chronic hematogenous osteomyelitis, right shoulder
M86.512 Other chronic hematogenous osteomyelitis, left shoulder
M86.521 Other chronic hematogenous osteomyelitis, right humerus
M86.522 Other chronic hematogenous osteomyelitis, left humerus
M86.531 Other chronic hematogenous osteomyelitis, right radius and ulna
M86.532 Other chronic hematogenous osteomyelitis, left radius and ulna
M86.541 Other chronic hematogenous osteomyelitis, right hand
M86.542 Other chronic hematogenous osteomyelitis, left hand
M86.551 Other chronic hematogenous osteomyelitis, right femur
M86.552 Other chronic hematogenous osteomyelitis, left femur
M86.561 Other chronic hematogenous osteomyelitis, right tibia and fibula
M86.562 Other chronic hematogenous osteomyelitis, left tibia and fibula
M86.571 Other chronic hematogenous osteomyelitis, right ankle and foot
M86.572 Other chronic hematogenous osteomyelitis, left ankle and foot
M86.58 Other chronic hematogenous osteomyelitis, other site
M86.59 Other chronic hematogenous osteomyelitis, multiple sites
M86.611 Other chronic osteomyelitis, right shoulder
M86.612 Other chronic osteomyelitis, left shoulder
M86.621 Other chronic osteomyelitis, right humerus
M86.622 Other chronic osteomyelitis, left humerus
M86.631 Other chronic osteomyelitis, right radius and ulna
M86.632 Other chronic osteomyelitis, left radius and ulna
M86.641 Other chronic osteomyelitis, right hand
M86.642 Other chronic osteomyelitis, left hand
M86.651 Other chronic osteomyelitis, right thigh
M86.652 Other chronic osteomyelitis, left thigh
M86.661 Other chronic osteomyelitis, right tibia and fibula
M86.662 Other chronic osteomyelitis, left tibia and fibula
M86.671 Other chronic osteomyelitis, right ankle and foot
M86.672 Other chronic osteomyelitis, left ankle and foot
M86.68 Other chronic osteomyelitis, other site
M86.69 Other chronic osteomyelitis, multiple sites
R50.9 Fever, unspecified
T84.50XA Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter
T84.50XD Infection and inflammatory reaction due to unspecified internal joint prosthesis, subsequent encounter
T84.50XS Infection and inflammatory reaction due to unspecified internal joint prosthesis, sequela
T84.51XA Infection and inflammatory reaction due to internal right hip prosthesis, initial encounter
T84.51XD Infection and inflammatory reaction due to internal right hip prosthesis, subsequent encounter
T84.51XS Infection and inflammatory reaction due to internal right hip prosthesis, sequela
T84.52XA Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter
T84.52XD Infection and inflammatory reaction due to internal left hip prosthesis, subsequent encounter
T84.52XS Infection and inflammatory reaction due to internal left hip prosthesis, sequela
T84.59XA Infection and inflammatory reaction due to other internal joint prosthesis, initial encounter
T84.59XD Infection and inflammatory reaction due to other internal joint prosthesis, subsequent encounter
T84.59XS Infection and inflammatory reaction due to other internal joint prosthesis, sequela

Group 19

(3 Codes)
Group 19 Paragraph

The following diagnoses are applicable to Gallium 68-ga Gozetotide/PSMA-11 (Illuccix®) injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9597 to bill for this service effective the FDA approval date 12/17/2021. Use the "PI" or "PS" modifier.

When A9597 is billed in Part B outpatient setting, the diagnosis codes below will be paid, effective 12/17/21.

NOTE: The PI modifier is covered only when used in patients with suspected metastasis who are candidates for initial definite therapy or with suspected recurrence based on elevated serum prostate-specific antigen (PSA) level. Providers must amend the KX modifier on the claim to attest that the use of the PI modifier is per NCCN Guidelines.

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.

Group 19 Codes
CodeDescription
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

Group 20

(3 Codes)
Group 20 Paragraph

The following diagnoses are applicable to Gallium 68-ga gozetotide (LOCAMETZ®) injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9597 to bill for this service per the FDA approval date of 03/23/2022. Use the "PI" or "PS" modifier.

When A9597 is billed in the OPPS setting or in Part B outpatient setting, the diagnosis codes below will be paid, effective 03/23/2022.

NOTE: The PI modifier is covered only when used in patients with suspected metastasis who are candidates for initial definite therapy, with suspected recurrence based on elevated serum prostate-specific antigen (PSA) level or for selection of patients with metastatic prostate cancer, for whom lutetium Lu 177 vipivotide tetraxetan PSMA-directed therapy is indicated. Providers must amend the KX modifier on the claim to attest that the use of the PI modifier is per NCCN Guidelines.

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.

Group 20 Codes
CodeDescription
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

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

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.

CodeDescription
013x Hospital Outpatient

Revenue Codes

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.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
02/18/2022 R34

Added the following breast cancer DX codes to Group 14 in the ICD-10-CM Codes That Support Medical Necessity and indicated Z85.3 MUST be billed with either any of the C50.XXX or C79.81 in the Group 14 Paragraph.

C50.011

C50.012

C50.021

C50.022

C50.111

C50.112

C50.121

C50.122

C50.211

C50.212

C50.221

C50.222

C50.311

C50.312

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

C50.622

C50.811

C50.812

C50.821

C50.822

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 to Groups 16, 17 & 19

Corrected the link to CR12613 and changed the effective date to 05-20-2022 under Resources in the Article Text.

Removed the following statements in Groups 11 and 13 “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” & “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 NCD220.6.17 C.1a.

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 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” and the approved FDA label indications for the tracer to Group 20.

02/18/2022 R33

In the Article Text deleted the statement “The section below is quoted from the IOM Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 4, Section 220.6” per CR 12613 and changed formatting throughout the article text.

Under Indications and Limitations of Coverage in the Article Text, added the specific NCD numbers addressed in this article, added language indicating any uses of PET scans that are not specifically listed in the NCDs listed may be covered per local MAC discretion and removed NaF for PET imaging for oncologic conditions using the PI or PS modifier since this tracer is non-covered per NCD 220.6.19.

In the Group 6-10 Paragraphs under ICD-10-CM Codes that Support Medical Necessity, added A9552 as the tracer to use and clarified PS modifier is used for subsequent strategy.

In Group 10 Paragraph added Gallium 68- ga Gozetotide/PSMA-11 (Illuccix®), effective 12/17/2021 as a newly local contractor approved tracer.

01/01/2022 R32

Added the sentence “For providers to be paid appropriately, A9595 must be billed per mCi effective 01/01/2022” to the Group 17 Paragraph.

Added Group 19 Paragraph & Group 19 ICD-10 Codes for the new tracer Gallium 68-ga Gozetotide/PSMA-11 (Illuccix®) effective 12/17/21 when billed with A9597for the tracer, PET Scan codes 78811-78816 and the PI or PS modifier.

 

01/01/2022 R31

The code descriptions for 78429-78434, 78459,78491-78492, 78608-78609 and 78812-78816 changed per the 2022 CPT/HCPCS Code Update. Also, added A9595- piflufolastat F 18 (PYLARIFY®) to the table of CPT/HCPCS codes and the Group 17 Paragraph effective 01/01/2022 per the 2022 CPT/HCPCS Code Update. Clarified the statement for the use of PI modifier with PSMA-PET/CT or PSMA-PET/MRI in the initial staging of bone & soft tissue imaging in Groups 16 and 17 Paragraphs.

10/29/2021 R30

For the effective dates stated in Groups 14, 15 & 16, added a statement indicating the tracer will be paid to Part A facilities when billed with one of the DX codes listed for the specific group and added the NCD number for FDG Refractory Seizures in the Group 3 Paragraph

Deleted G31.1, from the JF AB article as this was missed with the previous update effective 10/29/2021

Correction to Revision History 26: C7B.01-C7B.09 when billed with A9592 were added effective for DOS 04/01/2021 

10/29/2021 R29

Updated the language in Paragraph 2 to provide documentation needed for coverage and DX codes to bill outside of a clinical trial and removed it from the Beta Amyloid Gr 4 Paragraph per NCD 220.6.13, and CR12376. Deleted the Gr2 DX codes G30.0, G30.1, G30.8, G31.09, G31.1, G31.84, G31.85, G40.011, G40.019, G40.111, G40.119, G40.211, G40.219, G40.301, G40.311, G40.319, G40.A01, G40.A09, G40.A11, G40.A19, G40.B11, G40.B19, G40.411, G40.419, G40.803, G40.804, G40.813, G40.814, G40.823, G40.824, G40.89, G40.911, G40.919, R41.1 in the ICD-10 Codes That Support Medical Necessity section per CR12376.

Changed Group 3 Paragraph and Codes to the coverage & DX codes criteria for NCD 220.6.9 FDG PET for Refractory Seizures and added G40.011, G40.019, G40.111, G40.119, G40.211, G40.219, G40.301, G40.311, G40.319, G40.A01, G40.A09, G40.A11, G40.A19, G40.B11, G40.B19, G40.411, G40.419, G40.803, G40.804, G40.813, G40.814, G40.823, G40.824, G40.89, G40.911, G40.919. Renumber the succeeding Groups 4-18.

 

10/01/2021 R28

Added the statement “Effective 09/10/2021, the NCCN Guidelines have been updated to allow PMSA-PET/CT or PMSA-PET/MRI with Ga-68 PSMA-11 to be considered effective for initial bone imaging with the use of the ‘PI’ modifier." to the Group 15 Paragraph and "Effective 09/10/2021, the NCCN Guidelines have been updated to allow PMSA-PET/CT or PMSA-PET/MRI with F 18 piflufolastat PSMA to be considered effective for initial bone imaging with the use of the ‘PI’ modifier." to the Group 16 Paragraph. Also effective 9/10/2021, the tracers C-11 Choline from Group 10 and Fluciclovine F18 from Group 12 with PET/CT or PET/MRI and the ‘PI’ modifier are allowed when equivocal results are on initial bone imaging; per the updated NCCN Guidelines for Prostate Cancer.

10/01/2021 R27

Clarified what tracers to use in Groups 1 and 2 in the ICD-10 Codes That Support Medical Necessity section.

Deleted the statement “Noridian will reimburse this product per 1 mCi administered to the specific patient. Providers should enter the dose administered with the name of the product in the comment field of the claim or enter the number of units administered in the units’ field of the claim to receive proper payment.” from Gr 16.

Effective 01/01/2021 added FDG PET Scan coverage for inflammation and Infection in the Group 17 Paragraph and associated diagnosis codes in the Gr 17 list of codes effective 01/01/2021.

Effective 10/01/2021,added C56.3 - Malignant neoplasm of bilateral ovaries and C84.7A - Anaplastic large cell lymphoma, ALK-negative, breast to the Gr 4 ICD-10 Codes and C79.63 -Secondary malignant neoplasm of bilateral ovaries to the Gr 5 ICD-10 Codes per the ICD-10 Annual Updates.

07/01/2021 R26

Effective 07/01/2021, added A9593 and A9594 for Gallium ga-68 psma-11 (UCSF) and Gallium ga-68 psma-11 (UCLA) respectively for the treatment of prostate cancer per CR12142 to Group 15. Added A9597 for piflufolastat F 18 (PYLARIFY®) to Group 16 effective 5/26/2021. Added Q0 and Q1 modifiers to the CPT/HCPCS Modifiers section. Updated formatting in both the CPT/HCPCS Codes and ICD-10 Codes that Support Medical Necessity sections.

Note: The effective date for the information in Revision History number 23 for CR 12027 is 04/01/2021 and not 10/01/2020 as indicated.

04/01/2021 R25

Deleted C9068 and added A9592 - Copper Cu64 Dotatate to the Group 1 CPT/HCPCS section. Replaced A9597/C9068 with A9552 in Group 14 Paragraph of the ICD-10-CM Codes That Support Medical Necessity section per CR 12029. Corrected CR number CR 9861 to CR 11907 in Group 13 Paragraph of the ICD-10-CM Codes That Support Medical Necessity section.

04/01/2021 R24

Effective 01/01/2021, added A9591- Fluoroestradiol f 18, diagnostic, 1 millicurie and C9068 in the OPPS to Group 1 CPT/HCPCS Codes section and to Group 10 list of Contractor Determined Coverage for FDA Labeled Indications of Proprietary Radiopharmaceuticals Paragraph. Added the statements: “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” with ICD-10-CM codes C79.81 and Z85.3 to Group 13 and the same statements for A9597/C9068 for Copper Cu64 Dotatate except needing to use either the PI or PS modifier with 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 Z85.520to the ICD-10-CM Codes That Support Medical Necessity sections respectively.

04/01/2021 R23

Added the following diagnosis codes under Group 4 List I;  Group 5 List II; Group 6 List III,  Group 7 List IV & Group 9 List VI effective 10/01/20 per CR 12027.

  • Group 4 List I
    • D47.Z2
    • D47.Z9
    • G13.0
  • Group 5 List II
    • C79.51
    • G13.0
  • Group 6 List III
    • C94.40
    • C94.41
    • C94.42
    • G13.0
  • Group 7 List IV
    • G13.0
  • Group 9 List VI
    • G13.0
01/01/2020 R22

The following updates were made to be consistent with the NCD 220.6.17 (CR 10859) by removing unspecified codes and adding missing diagnoses and are effective 01/01/2019.

List 1

Added: C44.01, C44.212, C44.219, C44.311, C44.319, C96.21, C96.22

Deleted: C02.3, C43.10, C43.30, C43.9, C44.300, C50.911, C50.912, C50.921, C50.922, C81.00, C81.10, C81.20, C81.30, C81.40, C81.70, C81.90, C82.00, C82.10, C82.20, C82.30, C82.40, C82.50, C82.60, C82.80, C82.90, C83.00, C83.10, C83.30, C83.50, C83.70, C83.80, C83.90, C84.00, C84.10, C84.40, C84.60, C84.70, C84.A0, C84.Z0, C84.90, C85.10, C85.20, C85.80, C85.90, C96.5, C96.6, R93.9, Z85.20, Z85.819

List II

Added: C44.510, C44.511, C44.519, C45.7, C54.0, C70.0, C70.1, Z85.43

Deleted: C26.0, C38.3, C39.0, C39.9, C44.90, C47.6, C49.6, C49.9, C55, C60.9, C62.91, C62.92, C63.9, C67.9, C68.9, C69.91, C69.92, C72.9, C7A.00, C77.9, C78.30, C78.80, C79.40, C79.9, Z85.00,  Z85.45, Z85.50, Z85.819

List III

Deleted: C94.40, C94.41, C94.42, C94.6

List IV

Deleted: D37.039, D37.9, D38.6, D39.10, D39.9, D40.10, D40.09, D41.00, D41.10, D41.20, D41.9, D42.9, D43.2, D43.9, D44.10, D44.9, D48.60, D49.0, D49.1, D49.2, D49.3, D49.4, D49.6, D49.7, D49.81, D49.89, D49.9

List V

Deleted: D47.Z9, D47.9

Group 11

Deleted: C7A.00, C78.30, C78.80

01/01/2020 R21

The following CPT codes are added to Group 2 applicable tracer codes: 78430, 78431, 78432, 78433 and 78434. The following CPT codes are added to Group 3 applicable tracer codes: 78429, 78432 and 78433. They were previously added in R18 to Group 1 diagnosis codes and this revision clarifies appropriate tracer codes.

01/01/2020 R20

As required by CR 10901, article is converted to a formal billing and coding type article. There is no change in coverage.

01/01/2020 R19

The following asterisked statement is removed from List I, “ *Non-small cell neoplasm of the lung may be covered under initial treatment strategy and subsequent treatment strategy. Small cell lung neoplasm is “covered” for the initial treatment strategy.” Small cell lung cancer is covered for both initial and subsequent treatment strategy. Appropriate diagnoses are and have been included in List I for subsequent treatment of small cell lung cancer, therefore there are no changes in List I diagnoses.

01/01/2020 R18

The following CPT codes are added per CR 11655: 78429, 78430, 78431, 78432, 78433 and 78434.

01/01/2020 R17

The following code descriptors were updated effective January 1, 2020: 78459, 78491, and 78492 (Group 1).

10/01/2019 R16

The following ICD-10 code is deleted from the Group 1 Covered ICD-10 Codes field, effective September 30, 2019: I48.2.

The following ICD-10 codes are added to the Group 1 Covered ICD-10 Codes field, effective October 1, 2019: I48.11, I48.19, I48.20, I48.21.

01/01/2019 R15

The following revisions were inadvertently left off the previous revision history:

The following diagnoses are moved from List I to List II: Z85.038-Z85.060.

List I: C18.9, Z85.038 and Z85.048 are deleted effective 9/30/2018.

Groups 9, 10, 12: R97.21 was added effective 1/1/2019.

01/01/2019 R14

The following codes are end-dated effective September 30, 2018: C43.11, C43.12, C44.102, C44.109, C44.122, C44.129, C44.192, C44.199, C4A.11 and C4A.12.

The following codes are added effective October 1, 2018: C43.111, C43.112, C43.121, C43.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1921, C44.1922, C44.1991, C44.1992 (List I) C4A.111, C4A.112, C4A.121 and C4A.122 (List II).

The following codes are deleted effective January 1, 2019: C00.9, C02.9, C04.9, C05.9, C06.80, C06.9, C08.9, C10.9, C11.9, C13.9, C14.0, C15.9, C16.9, C17.9, C21.0, C24.9, C25.9, C26.9, C31.9, C32.9, C34.91, C34.92, C4A.30, C4A.9, C44.310, C44.320, C44.390, C44.99, C45.9, C46.9, C47.9, C48.2, C51.9, C53.9, C54.9, C71.9, C72.50, C75.9, C7A.094, C7A.095, C7A.096, C79.10 and R92.8.

The following codes are added effective January 1, 2019: R77.9 (List III), C7B.01, C7B.02, C7B.03, C7B.04, C7B.09, C7B.1, C7B.8 (List II), C96.29 (List I), Z85.020, Z85.030, Z85.040, Z85.060 (List II), Z85.110 (List I), Z85.230, Z85.41, Z85.520, Z85.821 (List II).

NOTE: Whenever a personal history dx code (Z85.XXX) is on a claim, the claim must also contain a dx from the list of covered C, D, or R dx codes.

ICD-10 codes R93.41, R93.421, R93.422, and R93.49 are added effective 10/1/16, corrected from 10/1/2017.

The following diagnoses are moved from List I to List II: Z85.038-Z85.060.

 

 

 

12/15/2017 R13

Article is revised to end date coverage for A9580, effective 12/15/2017. Diagnoses C44.91 and C57.9 are deleted from List II effective 10/01/2015, per CR 10473.

10/01/2017 R12

Per Change Request 10318 the following changes are made:

Diagnoses R93.3, R93.41, R93.49, R93.421 and R93.422 are added to List I 10/01/2017.

Diagnoses R93.3, R93.41, R93.49, R93.421, R93.422, R94.02 and Z85.830 are added to List II 10/01/2017.

Note that the CR lists R93.4 as payable, effective 10/1/17. However, this code is truncated requiring 5 characters, effective  10/1/17, so it was not added.  

10/01/2017 R11

Per Change Request 10184 the following changes are made:

Diagnoses C49.A1, C49.A2, C49.A3, C49.A4, C49.A5 and C49.A9 are added to List II effective 10/1/2016.

Diagnoses C79.51, C79.52, C80.0 and C80.1 are deleted from List II effective 10/1/2015.

Tracer code A9599 is end dated 01/01/2018 per the Change Request 10184.

Diagnosis code C49.0 is moved from List I to List II.

The following diagnosis codes are added per the annual ICD-10-CM code update for contractor determined diagnoses for 78459, 78491, and 78492: I21.9, I21.A1, I21.A9, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84 and I50.89. 

The description of I50.1 is revised.

C96.2 was deleted from Group 5

04/01/2017 R10

Per Change Request 10086 the following changes are made: Diagnoses D03.0, D03.11, D03.12, D03.21, D03.22, D03.30, D03.39, D03.51, D03.52, D03.59, D03.61, D03.62, D03.71, D03.72, D03.8 and D03.9 are deleted from List I effective 10/1/2015. Diagnosis C61 is added as payable for A9588 effective 1/1/2017.

04/01/2017 R9 A9515, A9587 and A9588 were added to the HCPCS code section. PI and PS modifier usage was clarified for these tracers.
The following diagnosis is added for List VI: Z85.46, eff 10/1/15. The following diagnosis is added to List V, eff 10/1/15: D47.Z1.
The following diagnoses are added as covered for A9587 effective 4/1/2017: C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80 and C78.89.
01/01/2017 R8 R8 – Per CR 9861, added A9587 and A9588 and removed instruction to bill Fluciclovine F-18 and Gallium ga-68 with J9340.

The following diagnoses were deleted effective 1/1/17 per CR 9861:
List I: C00.2, C00.5, C03.9, C34.00, C34.10, C34.30, C34.80, C34.90, C43.20, C43.60, C43.70, C44.121, C44.191, C44.201, C44.221, C44.291, C50.029, C50.119, C50.129, C50.219, C50.229, C50.319, C50.329, C50.419, C50.429, C50.519, C50.529, C50.619, C50.629, C50.819, C50.829, C50.919, C50.929, C56.9, D03.10, D03.20, D03.60, D03.70,

List II: C40.00, C40.10, C40.20, C40.30, C40.80, C40.90, C44.601, C44.611, C44.621, C44.691, C44.701, C44.721, C44.791, C46.50, C47.10, C47.20, C49.10, C49.20, C57.00, C57.10, C57.20, C62.00, C62.10, C62.90, C63.00, C63.10, C64.9, C65.9, C66.9, C69.00, C69.10, C69.20, C69.30, C69.40, C69.50, C69.60, C69.80, C69.90, C72.20, C72.30, C72.40, C74.00, C74.10, C74.90, C76.40, C76.50, C78.00, C79.00, C79.60, C79.70, C4A.10, C4A.20, C4A.60, C4A.70.

Per CR9930, replaced C9461 with A9515, effective 1/1/2017.

The coding relating to CPT code 78608 and non-oncologic indications was corrected to state that clinical trial requirements pertain only to diagnosis G31.84.

ICD-10 codes C93.Z0, C93.Z1 and C93.Z2 were added to List III. These diagnoses were previously covered when listed as a code range. When the article was updated to remove code ranges and add singular specific diagnoses, they were inadvertently left out.
10/01/2016 R7 R7 – Article is revised to add Contractor Determined coverage for FDA approved tracers: Choline C11, eff 3/7/13, Gallium 68 Dotatate Injection, eff 9/15/16 and Fluciclovine F18, eff 10/1/16. Q9982 and Q9983 are added as payable effective for dates of service on/after 07/01/2016 per CR 9751. Diagnosis C88.0 is added as payable effective for dates of service on/after 7/25/2016. Diagnosis ranges are removed.

The following diagnoses are deleted effective 9/30/2016:
R93.4 – List I, D49.5, List IV, R97.2, List VI.


07/01/2016 R6 R6 – Article is revised to include Part A contract numbers.
10/01/2015 R5 Corrected hyperlink to CMS website in number 2 of the article text.
10/01/2015 R4 Article is revised to remove deletion of R91.8 in List I effective 04/15/16. This removal was in error.
10/01/2015 R3 Article is revised to clarify that modifiers PI and PS are required when billing scans with tracer HCPCS code A9580 for oncologic indications. Multiple diagnosis additions were added to Lists I, II and III to be consistent with CMS published diagnoses for the NCD. The following diagnoses are deleted effective 04/15/16:R91.8 from List I and D3A.010-D3A.029 from List II.
10/01/2015 R2 Article is revised to clarify that diagnosis Z00.6 is required in addition to the diagnoses listed in Group 3 when billing beta amyloid tracers A9586 and A9599.
10/01/2015 R1 Article revised to add ICD 10 code R91.8 for procedure codes 78811, 78812, 78813, 78814, 78815 and 78816 under Group 5 List 1

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