Oncologic FDG PET Coverage

An oncologic FDG PET scan is one in which fluorodeoxyglucose tracer is injected into the patient prior to the scan to help identify cancer. There are many misconceptions when it comes to Medicare reimbursement for oncologic FDG PET scans. It is very important to understand how to correctly code these studies and under what circumstances the scans may be covered.

Coding FDG PET Scans

Oncologic FDG PET scans are reported with the PET body scan codes (78811-78816) and/or the PET metabolic brain scan code (78608).

78608 Brain imaging, positron emission tomography (PET); metabolic evaluation

78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)

78812 . . . skull base to mid-thigh

78813 . . . 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 . . . skull base to mid-thigh

78816 . . . whole body

The “limited area” codes are reported when only a single body area is studied, or when the scan does not extend from skull base to mid-thigh. The “whole body” codes are reported when the scan extends from the top of the head (vertex) down to the feet or lower leg.

In order to report the PET/CT codes, the PET and CT scans must be acquired concurrently, meaning at the same encounter on the same scanner.

Initial Treatment Strategy

Medicare’s National Coverage Determination (NCD 220.6.17) discusses Medicare coverage for oncologic FDG PET scans: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf

The NCD classifies oncologic FDG scan as either initial treatment strategy or subsequent treatment strategy. A scan falls into the initial treatment strategy category when it is performed to determine the physician’s initial treatment strategy for a tumor that is “biopsy proven or strongly suspected of being cancerous based on other diagnostic imaging.” These scans must be submitted to Medicare with modifier 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] applied to the scan code. The initial treatment study must be ordered to determine:

  • Whether the patient is a candidate for an invasive diagnostic or therapeutic procedure; or
  • The optimal anatomical location of the invasive procedure; or
  • The anatomic extent of the tumor when that information will determine the treatment recommendations.

The initial treatment strategy category includes scans performed for staging.

The NCD allows coverage for only one initial treatment strategy scan per cancer per patient. For example, an initial treatment strategy scan is performed for breast cancer, and years later, another initial treatment strategy scan is performed for colon cancer. Both scans can be billed as initial treatment strategy scans. Local Medicare contractors and Medicare Advantage plans may cover additional initial treatment strategy scans if desired. It is best practice to document the medical necessity of the second initial treatment strategy scan.

Subsequent Treatment Strategy

Subsequent treatment strategy scans are defined by the Medicare NCD as those performed to “guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy.” This is often referred to as restaging. Medicare does not consider subsequent treatment strategy scans as those performed for surveillance purposes in a patient with previously treated cancer who has no clinical evidence of active disease. This would be considered a screening.

Modifier 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] must be applied to the scan code for subsequent treatment strategy scans submitted to Medicare. The NCD allows coverage of no more than three subsequent treatment strategy scans. If the patient has more than one type of cancer, there is a separate 3-scan limit for each cancer.

Local Medicare contractors and Medicare Advantage plans may cover additional scans if desired. If Medicare criteria are met, modifier KX (Requirements specified in the medical policy have been met) should be applied to the code(s) for the fourth and subsequent scans. Modifier KX is applied in addition to modifier PS, not instead of it. Providers should consider issuing an Advance Beneficiary Notice for the fourth and subsequent scans, as the Medicare contractor may determine they are not medically necessary.

Coverage Limitations

The following table summarizes Medicare coverage for oncologic PET, PET-CT, and PET-MRI scans using FDG. Medicare will pay for the scans listed as covered if the scan is medically necessary, ordered by the treating physician, and submitted with a covered diagnosis code.

Tumor Type Initial Treatment Strategy Subsequent Treatment Strategy
Colorectal Covered Covered
Esophagus Covered Covered
Head and neck (except thyroid and CNS) Covered Covered
Lymphoma Covered Covered
Non-small cell lung cancer Covered Covered
Ovary Covered Covered
Brain Covered Covered
Cervix Covered with exceptions Covered
Small cell lung cancer Covered Covered
Soft tissue sarcoma Covered Covered
Pancreas Covered Covered
Testicular Covered Covered
Prostate Noncovered Covered
Thyroid Covered Covered
Breast (female and male) Covered with exceptions Covered
Melanoma Covered with exceptions Covered
All other solid tumors Covered Covered
Myeloma Covered Covered
All other cancers not listed Covered Covered

Initial treatment strategy scans for prostate cancer are noncovered and will not be paid under any circumstances.

Three types of scans are subject to restricted coverage:

  • Cervical cancer: Initial treatment scans are covered only for the staging of biopsy-proven cervical cancer. Scans performed for diagnosis of cervical cancer are noncovered.
  • Male and female breast cancer: Initial treatment strategy scans are noncovered for initial diagnosis and/or staging of axillary lymph nodes. Initial treatment strategy scans are covered for initial staging of metastatic disease.
  • Melanoma: Initial treatment strategy scans are non-covered for initial staging of regional lymph nodes. All other uses for initial staging are covered.

If it is necessary to submit a claim to Medicare for a study that does not meet Medicare coverage requirements, one of the following HCPCS codes for noncovered PET scans must be reported:

G0219 PET imaging whole body; melanoma for non-covered indications

G0235 PET imaging, any site, not otherwise specified

G0252 PET imaging, full or 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)

Diagnosis Codes

The following link can be found in the Medicare Claims Processing Manual (Chapter 13, Section 60.16) and includes a list of “appropriate diagnosis codes” for oncologic PET scans: http://cms.gov/medicare/coverage/determinationprocess/ downloads/petforsolidtumorsoncologicdxcodesattachment_NCD220_6_17.pdf

The list is periodically updated, so be sure to review it often. In additional to neoplasm codes, the list includes codes for certain abnormal findings, such as solitary pulmonary nodule (R91.1) and personal history of certain types of malignant neoplasms, such as breast cancer (Z85.3). Claims without a covered diagnosis will be denied.

Medicare denials of oncologic FDG PET scans can be a problem. Always check payer guidelines for coverage requirements and use the information provided to help prevent denials.

- Article by Coding Strategies® Staff