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OtherPROFESSIONAL DEVELOPMENT

FDG PET Reimbursement

Jim Bietendorf
Journal of Nuclear Medicine Technology March 2004, 32 (1) 33-38;
Jim Bietendorf
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    TABLE 1

    Medicare Covered Clinical Conditions, HCPCS/CPT Codes, and Descriptions for FDG PET—Coincidence Gamma Camera Only

    Covered clinical conditionCodeCode description
    Colorectal CancerG0231PET, whole body, for recurrence of colorectal or colorectal metastatic cancer
     Determining location of colorectal tumors if rising CEA level suggests recurrence
    LymphomaG0232PET, whole body, for recurrence of lymphoma
     Staging or restaging of lymphoma only when used as an alternative to a gallium scan
    MelanomaG0233PET, 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)G0234PET, 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
    • View popup
    TABLE 2

    Medicare 2004 HOPPS Payment Rates for FDG PET

    HCPCS/CPT codesAPC codeMedicare APC paymentTotal scan payments
    FDG, per doseC17751775$324.48—
    Dedicated FDG PETG0125, G0210–G0218, G0220–G0229, G0253–G0254, G02961516$1,450.00$1,774.48
    Gamma Camera FDG PETG0231–G02341516$1,450.00$1,774.48
    Myocardial ViabilityG02301516$1,450.00$1,774.48
    Myocardial Viability784590285$772.08$1,096.59
    • View popup
    TABLE 3

    Medicare Covered Clinical Conditions, HCPCS/CPT Codes and Descriptions for FDG PET— Dedicated FDG PET Scanners Only

    Covered clinical conditionCodeCode description
    Single Pulmonary Nodule (SPN)
     Characterization of single pulmonary nodules following CT, lesion not to exceed 4 cmG0125PET imaging; regional or whole body; single pulmonary nodule
    Lung Cancer–Non Small Cell
     DiagnosisG0210PET imaging whole body; diagnosis; lung cancer, non-small cell
     StagingG0211PET imaging whole body; initial staging; lung cancer, non-small cell
     RestagingG0212PET imaging whole body; restaging; lung cancer, non-small cell
    Colorectal Cancer
     DiagnosisG0213PET imaging whole body; diagnosis; colorectal cancer
     StagingG0214PET imaging whole body; initial staging; colorectal cancer
     RestagingG0215PET imaging whole body; restaging; colorectal cancer
    Melanoma (not covered for evaluating regional nodes)
     DiagnosisG0216PET imaging whole body; diagnosis; melanoma
     StagingG0217PET imaging whole body; initial staging; melanoma
     RestagingG0218PET imaging whole body; restaging; melanoma
     Non-covered indicationsG0219PET imaging whole body; melanoma, for non-covered indications
    Lymphoma
     DiagnosisG0220PET imaging whole body; diagnosis; lymphoma
     StagingG0221PET imaging whole body; initial staging; lymphoma
     RestagingG0222PET imaging whole body; restaging; lymphoma
    Head and Neck Cancer (excluding CNS and thyroid cancers)
     DiagnosisG0223PET imaging whole body or regional; diagnosis; head and neck cancer
     StagingG0224PET imaging whole body or regional; initial staging; head and neck cancers
     RestagingG0225PET imaging whole body or regional; restaging; head and neck cancers
    Esophageal Cancer
     DiagnosisG0226PET imaging whole body; diagnosis; esophageal cancer
     StagingG0227PET imaging whole body; initial staging; esophageal cancer
     RestagingG0228PET imaging whole body; restaging; esophageal cancer
    Pre-surgical evaluation of refractory seizuresG0229PET imaging; metabolic brain imaging for pre-surgical evaluation of refractory seizures
    Myocardial ViabilityG0230PET imaging; metabolic assessment for myocardial viability following an inconclusive SPECT study
    Myocardial Viability78459PET imaging; metabolic evaluation for determination of myocardial viability as a primary or initial diagnostic study prior to revascularization
    Breast Cancer
     Diagnosis (not covered)G0252PET 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/restagingG0253PET 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 treatmentG0254PET imaging for breast cancer; evaluation of response to treatment, performed during course of treatment
    Thyroid Cancer
     RestagingG0296PET imaging; for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan
    • View popup
    TABLE 4

    CPT Codes for PET Scans

    CPT codeDescription
    78810Tumor imaging, PET, metabolic evaluation
    78459Myocardial imaging, PET, metabolic evaluation
    78491Myocardial imaging, PET, perfusion; single study at rest or stress
    78492Myocardial imaging, PET, perfusion; multiple studies at rest and/or stress
    78608Brain imaging, PET, metabolic evaluation
    78609Brain imaging, PET, perfusion evaluation
    78990 or A4641Provision of a diagnostic radiopharmaceutical
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Journal of Nuclear Medicine Technology: 32 (1)
Journal of Nuclear Medicine Technology
Vol. 32, Issue 1
March 1, 2004
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Journal of Nuclear Medicine Technology Mar 2004, 32 (1) 33-38;

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  • 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
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