October 25, 2007
Payable diagnosis codes for PET Scans
Medicare coverage for PET scans is determined by National Coverage Determinations (NCD). Only those diagnoses/conditions specifically designated as covered may be paid, except for some malignancies which are not specifically named. Some such cancers can be covered if the institution performing the study is participating in the National Oncology PET Registry (NOPR), but not otherwise.
When several of the PET NCDs and coverages first were implemented, the PET scan procedures covered were designated by temporary “G” codes that were condition-specific and corresponded to the NCD coverages. The covered conditions could easily be linked to the corresponding G code for payment. Subsequently, AMA/CPT and CMS published CPT codes for PET scans that were anatomically and functionally oriented, and deleted the G codes. This created somewhat of a disconnect between the condition-specific coverages as defined in the NCDs and the CPT codes describing the procedures. Numerous provides have asked which ICD-9 diagnoses are covered for which procedure (CPT code). This is published to provide our coverages based on the specific NCDs.
CPT Code |
Payable Diagnoses/ICD-9 Codes |
78608-PET brain imaging; metabolic evaluation |
290.0, 290.10-290.13, 290.20-290.21, 290.3, 294.10-294.11, 331.0, 331.11, 331.19, 331.2, 345.01, 345.11, 345.2, 345.3, 345.41, 345.51, 345.61, 345.71, 345.8, 345.91, 780.93 |
78609- PET brain imaging; perfusion evaluation |
290.0, 290.10-290.13, 290.20-290.21, 290.3, 294.10-294.11, 331.0, 331.11, 331.19, 331.2, 345.01, 345.11, 345.2, 345.3, 345.41, 345.51, 345.61, 345.71, 345.8, 345.91, 780.93 |
78459- PET myocardial imaging ;metabolic evaluation |
410.0-414.9 |
78491-PET heart image; single study |
410.0-414.9 |
78492-PET heart image;multiple studies |
410.0-414.9 |
78811-PET tumor imaging in limited area (head, chest/neck) |
140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1 |
78812-PET tumor imaging skull base to mid-thigh |
140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1 |
78813-PET tumor imaging; whole body |
140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1 |
78814-PET tumor imaging w/concurrent CT for attenuation correction and anatomical localization; limited area(head/neck, chest) |
140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1 |
78815-PET tumor imaging w/concurrent CT for attenuation correction and anatomical localization: skull base to mid-thigh |
140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1 |
78816-PET tumor imaging w/concurrent CT for attenuation correction and anatomical localization; whole body |
140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1 |
