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February 14, 2018

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Medical Coding News Archives

Medicare Covers PET Aß Scanning Under Certain Circumstances

April 3, 2014:

Deborah C. Hall, New Product Subject Matter Expert

In a recently released transmittal (Transmittal 160), the Centers for Medicare and Medicaid Services announced that Medicare will cover positive emission tomography beta amyloid (PET Aß) imaging performed on or after September 27, 2013. The transmittal indicates that Medicare will provide coverage with evidence development (CED) during a clinical trial for PET Aß imaging performed to:

  • Develop better treatments or prevention strategies for patients with Alzheimer’s disease or as a strategy to identify subpopulations who are at risk for developing the disease
  • Resolve clinically difficult differential diagnoses (such as frontotemporal dementia versus Alzheimer’s disease) where the use of the PET Aß imaging appears to improve health outcomes, when the patient is enrolled in an approved clinical study under CED

Improved health outcomes related to this coverage determination may be short-term or long-term and include:

  • Avoidance of unnecessary or potentially harmful treatment or tests
  • Improved, slowed decline of the quality of life, including the maintenance of the patient’s independence and cognitive/functional status
  • Survival

Medicare will return claims as unprocessable if they do not contain the following:

  • Condition code 30
  • Modifier Q0 and/or Q1 as appropriate
  • ICD-9-CM diagnosis code V70.7 or ICD-10-CM code Z00.6 in either the primary or secondary position
  • Procedure code 78811 or 78814
  • Aß HCPCS code A9586 or A9599
  • ICD-9-CM diagnosis codes 290.0–290.43, 294.10–294.21, 331.11–331.19, 331.6, 331.82–331.83, or 780.93
  • On or after October 1, ICD-10-CM codes F01.50–F01.51, F02.80–F02.81, F03.90–F03.91, G31.01, G31.09, G31.83–G31.85, or R41.1–R41.3

Click here for more information regarding the coverage of and submission of claims for PET Aß scans.


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