78609
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records must be maintained and available upon request, be legible, include complete patient identification and dates of service, and contain the legible signature of the physician or non‑physician practitioner responsible for care.
- The submitted medical record must support the selected ICD‑10‑CM diagnosis code(s) and the CPT/HCPCS code billed must accurately describe the service performed.
- When FDG PET is performed in the context of a CMS‑approved practical clinical trial using a specific protocol, the claim should be reported with modifier Q0.
- When only the technical or professional component is performed, report the PET procedure with modifier TC (technical) or 26 (professional), respectively.
Key Coverage Criteria
- FDG PET (CPT 78608 / HCPCS A9552) is covered to differentiate Alzheimer's disease (AD) from frontotemporal dementia (FTD) in patients with a recent dementia diagnosis who have documented cognitive decline for at least 6 months and who meet diagnostic criteria for both AD and FTD.
- FDG PET is covered for patients with mild cognitive impairment (MCI) or early dementia only when performed as part of a CMS‑approved practical clinical trial (coverage with evidence development).
- FDG PET (CPT 78608) is covered for intractable seizures only when used as part of a pre‑surgical evaluation for seizure focus localization.
- An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
- Additional services and supplies (e.g., radiopharmaceuticals, special contrast agents, medications) are payable to an IDTF when the diagnostic test itself is payable and the supplies are commonly separately reimbursed to a physician in an office setting.
- A supervising physician for an IDTF must be licensed in the state(s) where tests are performed, enrolled in Medicare, not excluded, meet proficiency standards for tests supervised, and provide general supervision for no more than three IDTF sites.
11 Active Policies
A59049 — Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions
J09
A53134 — Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions
J12
AETNA-CPB-0614 — Huntington's Disease
A58559 — Billing and Coding: Independent Diagnostic Testing Facilities (IDTF)
Related Codes
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