SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Positron Emission Tomography (PET) Scan for Inflammation and Infection

A59318

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59318
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Positron Emission Tomography (PET) Scan for Inflammation and Infection
Article Type
Billing and Coding
Original Effective Date
08/13/2023
Revision Effective Date
08/13/2023
Revision Ending Date
11/21/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

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Article Guidance

Article Text

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The patient’s medical record should include but is not limited to:

  • Relevant medical history
  • Physical examination findings
  • Results of pertinent tests/procedures
  • Imaging testing performed
  • Rationale for decision for PET scan including rationale for PET scan over standard imaging modalities and why PET was necessary
  • Results of PET scan
  • Documentation in medical record of the role PET scan plays in clinical management
  • In cases of fever of unknown fever curve with temperatures and documentation of ≥ 21 days since onset of fever and fevers in the 2 weeks prior to the study.

Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate the

reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will

be returned.

The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report(s) and copies of images. The computerized image reconstruction data should also be maintained.

Documentation must be available to Medicare upon request.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(9 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
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
A9552 FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES
A9598 POSITRON EMISSION TOMOGRAPHY RADIOPHARMACEUTICAL, DIAGNOSTIC, FOR NON-TUMOR IDENTIFICATION, NOT OTHERWISE CLASSIFIED
A9601 FLORTAUCIPIR F 18 INJECTION, DIAGNOSTIC, 1 MILLICURIE

Group 2

(4 Codes)
Group 2 Paragraph

N/A

Group 2 Codes
Code Description
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
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
78459 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED), SINGLE STUDY;

Group 3

(6 Codes)
Group 3 Paragraph

The following apply to A9552 (FLUORODEOXYGLUCOSE F-18 FDG)

Group 3 Codes
Code Description
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

Group 4

(5 Codes)
Group 4 Paragraph

The following CPT/HCPCS are Non-Covered.

Group 4 Codes
Code Description
78608 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC EVALUATION
78609 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION EVALUATION
G0219 PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED INDICATIONS
G0235 PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED
G0252 PET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY, FOR INITIAL DIAGNOSIS OF BREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER (E.G., INITIAL STAGING OF AXILLARY LYMPH NODES)
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

The ICD-10-CM diagnosis codes in Group 1 support the medical necessity of the CPT/HCPCS Code section-Group1 above.

Group 1 Codes
Code Description
R50.9 Fever, unspecified

Group 2

(10 Codes)
Group 2 Paragraph

The ICD-10-CM diagnosis codes in Group 2 support the medical necessity of the CPT/HCPCS Code section-Group 2 above.

 

Group 2 Codes
Code Description
D86.85 Sarcoid myocarditis
M31.4 Aortic arch syndrome [Takayasu]
M31.5 Giant cell arteritis with polymyalgia rheumatica
M31.6 Other giant cell arteritis
T82.6XXA* Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter
T82.6XXD* Infection and inflammatory reaction due to cardiac valve prosthesis, subsequent encounter
T82.6XXS* Infection and inflammatory reaction due to cardiac valve prosthesis, sequela
T82.7XXA* Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
T82.7XXD* Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter
T82.7XXS* Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, sequela
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*T82.6 and T82.7 require additional code to identify infection

Group 3

(74 Codes)
Group 3 Paragraph

The following apply to A9552

Group 3 Codes
Code Description
M46.40 - M46.49 Discitis, unspecified, site unspecified - Discitis, unspecified, multiple sites in spine
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
N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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.

Code Description
N/A

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.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
08/13/2023 R2

Revision Effective: 08/13/2023

Revision Explanation: Corrected the radiopharmaceutical code listed in group 3 paragraph in the ICD-10 section from A9553 to A9552. Removed CPT codes 78608 and 78609 from group 3 list under CPT and HCPCS section as they were included in error.

08/13/2023 R1

Revision Effective: 08/13/2023

Revision Explanation: Corrected the radiopharmaceutical code listed in group 3 paragraph in teh CPT/HCPCS section from A9553 to A9552.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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SAD Process URL 2
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Updated On Effective Dates Status
11/15/2023 11/22/2023 - N/A Currently in Effect View
08/24/2023 08/13/2023 - 11/21/2023 Superseded You are here
07/25/2023 08/13/2023 - N/A Superseded View
06/22/2023 08/13/2023 - N/A Superseded View

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