Article Figures & Data
Tables
- TABLE 1
Medicare Covered Clinical Conditions, HCPCS/CPT Codes, and Descriptions for FDG PET—Coincidence Gamma Camera Only
Covered clinical condition Code Code description Colorectal Cancer G0231 PET, whole body, for recurrence of colorectal or colorectal metastatic cancer Determining location of colorectal tumors if rising CEA level suggests recurrence Lymphoma G0232 PET, whole body, for recurrence of lymphoma Staging or restaging of lymphoma only when used as an alternative to a gallium scan Melanoma G0233 PET, whole body, for recurrence of melanoma or melanoma metastatic cancer Evaluating recurrence of melanoma prior to surgery as an alternative to a gallium scan Single Pulmonary Nodule (SPN) G0234 PET, regional or whole body, for single pulmonary nodule following CT, or for initial staging of pathologically diagnosed non-small cell lung cancer Characterization of single pulmonary nodules following CT, lesion not to exceed 4 cm or Lung Cancer—Non Small Cell Initial Staging HCPCS/CPT codes APC code Medicare APC payment Total scan payments FDG, per dose C1775 1775 $324.48 — Dedicated FDG PET G0125, G0210–G0218, G0220–G0229, G0253–G0254, G0296 1516 $1,450.00 $1,774.48 Gamma Camera FDG PET G0231–G0234 1516 $1,450.00 $1,774.48 Myocardial Viability G0230 1516 $1,450.00 $1,774.48 Myocardial Viability 78459 0285 $772.08 $1,096.59 - TABLE 3
Medicare Covered Clinical Conditions, HCPCS/CPT Codes and Descriptions for FDG PET— Dedicated FDG PET Scanners Only
Covered clinical condition Code Code description Single Pulmonary Nodule (SPN) Characterization of single pulmonary nodules following CT, lesion not to exceed 4 cm G0125 PET imaging; regional or whole body; single pulmonary nodule Lung Cancer–Non Small Cell Diagnosis G0210 PET imaging whole body; diagnosis; lung cancer, non-small cell Staging G0211 PET imaging whole body; initial staging; lung cancer, non-small cell Restaging G0212 PET imaging whole body; restaging; lung cancer, non-small cell Colorectal Cancer Diagnosis G0213 PET imaging whole body; diagnosis; colorectal cancer Staging G0214 PET imaging whole body; initial staging; colorectal cancer Restaging G0215 PET imaging whole body; restaging; colorectal cancer Melanoma (not covered for evaluating regional nodes) Diagnosis G0216 PET imaging whole body; diagnosis; melanoma Staging G0217 PET imaging whole body; initial staging; melanoma Restaging G0218 PET imaging whole body; restaging; melanoma Non-covered indications G0219 PET imaging whole body; melanoma, for non-covered indications Lymphoma Diagnosis G0220 PET imaging whole body; diagnosis; lymphoma Staging G0221 PET imaging whole body; initial staging; lymphoma Restaging G0222 PET imaging whole body; restaging; lymphoma Head and Neck Cancer (excluding CNS and thyroid cancers) Diagnosis G0223 PET imaging whole body or regional; diagnosis; head and neck cancer Staging G0224 PET imaging whole body or regional; initial staging; head and neck cancers Restaging G0225 PET imaging whole body or regional; restaging; head and neck cancers Esophageal Cancer Diagnosis G0226 PET imaging whole body; diagnosis; esophageal cancer Staging G0227 PET imaging whole body; initial staging; esophageal cancer Restaging G0228 PET imaging whole body; restaging; esophageal cancer Pre-surgical evaluation of refractory seizures G0229 PET imaging; metabolic brain imaging for pre-surgical evaluation of refractory seizures Myocardial Viability G0230 PET imaging; metabolic assessment for myocardial viability following an inconclusive SPECT study Myocardial Viability 78459 PET imaging; metabolic evaluation for determination of myocardial viability as a primary or initial diagnostic study prior to revascularization Breast Cancer Diagnosis (not covered) G0252 PET imaging; for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g. initial staging of axillary lymph nodes), not covered by Medicare Staging/restaging G0253 PET imaging for breast cancer; staging/restaging, of local regional recurrence or distant metastases, i.e., staging/restaging after or prior to course of treatment Evaluation of response to treatment G0254 PET imaging for breast cancer; evaluation of response to treatment, performed during course of treatment Thyroid Cancer Restaging G0296 PET imaging; for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan CPT code Description 78810 Tumor imaging, PET, metabolic evaluation 78459 Myocardial imaging, PET, metabolic evaluation 78491 Myocardial imaging, PET, perfusion; single study at rest or stress 78492 Myocardial imaging, PET, perfusion; multiple studies at rest and/or stress 78608 Brain imaging, PET, metabolic evaluation 78609 Brain imaging, PET, perfusion evaluation 78990 or A4641 Provision of a diagnostic radiopharmaceutical
Jump to section
- Article
- EVOLUTION OF CMS FDG PET REIMBURSEMENT
- MEDICARE PAYMENT RATES FOR HOSPITAL OUTPATIENTS
- MEDICARE PAYMENT RATES IN FREESTANDING FACILITIES
- MEDICARE PAYMENT RATES TO PHYSICIANS
- MEDICARE COVERAGE BY ALLOWABLE TYPE OF FDG PET SCANNER
- MEDICARE CONDITIONS OF COVERAGE
- CONDITIONS ON FREQUENCY
- MEDICARE LOCAL VARIABILITY
- PRIVATE PAYER COVERAGE AND BILLING FOR FDG PET
- FUTURE EXPANDED COVERAGE OF PET BY MEDICARE
- Summary
- REFERENCES
- Figures & Data
- Info & Metrics