PET Scan Qualifying Conditions and HCPCS Code Chart

60.3 - PET Scan Qualifying Conditions and HCPCS Code Chart (Rev. 527, Issued: 04-15-05, Effective: 01-28-05, Implementation: 04-18-05) Below is a summary of all covered PET scan conditions, with effective dates. NOTE: The G codes below except those a # can be used to bill for PET Scan services through January 27, 2005. Effective for dates of service on or after January 28, 2005, providers must bill for PET Scan services using the appropriate CPT codes. See section 60.3.1. The G codes with a # can continue to be used for billing after January 28, 2005 and these remain non-covered by Medicare. (NOTE: PET Scanners must be FDA-approved.) Conditions Coverage Effective Date ****HCPCS/CPT *Myocardial perfusion imaging (following previous PET G0030-G0047) single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0030 *Myocardial perfusion imaging (following previous PET G0030-G0047) multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0031 *Myocardial perfusion imaging (following rest SPECT, 78464); single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0032 *Myocardial perfusion imaging (following rest SPECT 78464); multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0033 *Myocardial perfusion (following stress SPECT 78465); single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0034 *Myocardial Perfusion Imaging (following stress SPECT 78465); multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0035 *Myocardial Perfusion Imaging (following coronary angiography 93510-93529); single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0036 *Myocardial Perfusion Imaging, (following coronary angiography), 93510-93529); multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0037 *Myocardial Perfusion Imaging (following stress planar myocardial perfusion, 78460); single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0038 Conditions Coverage Effective Date ****HCPCS/CPT *Myocardial Perfusion Imaging (following stress planar myocardial perfusion, 78460); multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0039 *Myocardial Perfusion Imaging (following stress echocardiogram 93350); single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0040 *Myocardial Perfusion Imaging (following stress echocardiogram, 93350); multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0041 *Myocardial Perfusion Imaging (following stress nuclear ventriculogram 78481 or 78483); single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0042 *Myocardial Perfusion Imaging (following stress nuclear ventriculogram 78481 or 78483); multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0043 *Myocardial Perfusion Imaging (following stress ECG, 93000); single study, rest or stress (exercise and/or pharmacologic) 3/14/95 G0044 *Myocardial perfusion (following stress ECG, 93000), multiple studies; rest or stress (exercise and/or pharmacologic) 3/14/95 G0045 *Myocardial perfusion (following stress ECG, 93015), single study; rest or stress (exercise and/or pharmacologic) 3/14/95 G0046 *Myocardial perfusion (following stress ECG, 93015); multiple studies, rest or stress (exercise and/or pharmacologic) 3/14/95 G0047 PET imaging regional or whole body; single pulmonary nodule 1/1/98 G0125 Conditions Coverage Effective Date ****HCPCS/CPT Lung cancer, non-small cell (PET imaging whole body) Diagnosis, Initial Staging, Restaging 7/1/01 G0210 G0211 G0212 Colorectal cancer (PET imaging whole body) Diagnosis, Initial Staging, Restaging 7/1/01 G0213 G0214 G0215 Melanoma (PET imaging whole body) Diagnosis, Initial Staging, Restaging 7/1/01 G0216 G0217 G0218 Melanoma for non-covered indications 7/1/01 #G0219 Lymphoma (PET imaging whole body) Diagnosis, Initial Staging, Restaging 7/1/01 G0220 G0221 G0222 Head and neck cancer; excluding thyroid and CNS cancers (PET imaging whole body or regional) Diagnosis, Initial Staging, Restaging 7/1/01 G0223 G0224 G0225 Esophageal cancer (PET imaging whole body) Diagnosis, Initial Staging, Restaging 7/1/01 G0226 G0227 G0228 Metabolic brain imaging for pre-surgical evaluation of refractory seizures 7/1/01 G0229 Metabolic assessment for myocardial viability following inconclusive SPECT study 7/1/01 G0230 Recurrence of colorectal or colorectal metastatic cancer (PET whole body, gamma cameras only) 1/1/02 G0231 Staging and characterization of lymphoma (PET whole body, gamma cameras only) 1/1/02 G0232 Conditions Coverage Effective Date ****HCPCS/CPT Recurrence of melanoma or melanoma metastatic cancer (PET whole body, gamma cameras only) 1/1/02 G0233 Regional or whole body, for solitary pulmonary nodule following CT, or for initial staging of non- small cell lung cancer (gamma cameras only) 1/1/02 G0234 Non-Covered Service PET imaging, any site not otherwise specified 1/28/05 #G0235 Non-Covered Service Initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes), not covered (full- and partial- ring PET scanners only) 10/1/02 #G0252 Breast cancer, staging/restaging of local regional recurrence or distant metastases, i.e., staging/restaging after or prior to course of treatment (full- and partial-ring PET scanners only) 10/1/02 G0253 Breast cancer, evaluation of responses to treatment, performed during course of treatment (full- and partial-ring PET scanners only) 10/1/02 G0254 Myocardial imaging, positron emission tomography (PET), metabolic evaluation) 10/1/02 78459 Restaging or previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan (full- and partial-ring PET scanner only) 10/1/03 G0296 Tracer Rubidium**82 (Supply of Radiopharmaceutical Diagnostic Imaging Agent) (This is only billed through Outpatient Perspective Payment System, OPPS.) (A/B MACs (B) must use HCPCS Code A4641). 10/1/03 Q3000 ***Supply of Radiopharmaceutical Diagnostic Imaging Agent, Ammonia N-13*** 01/1/04 A9526 Conditions Coverage Effective Date ****HCPCS/CPT PET imaging, brain imaging for the differential diagnosis of Alzheimer’s disease with aberrant features vs. fronto-temporal dementia 09/15/04 Appropriate CPT Code from section 60.3.1 PET Cervical Cancer Staging as adjunct to conventional imaging, other staging, diagnosis, restaging, monitoring 1/28/05 Appropriate CPT Code from section 60.3.1 *NOTE: A/B MACs (B) must report A4641 for the tracer Rubidium 82 when used with PET scan codes G0030 through G0047 for services performed on or before January 27, 2005 **NOTE: Not FDG PET ***NOTE: For dates of service October 1, 2003, through December 31, 2003, use temporary code Q4078 for billing this radiopharmaceutical.