Provider Documentation Required with the PET Scan Claim

Medicare contractors shall inform providers to ensure the conditions mentioned in the NCD Manual, section 220.6.13, have been met. The information must also be maintained in the beneficiary’s medical record:

– Date of onset of symptoms;
– Diagnosis of clinical syndrome (normal aging, mild cognitive impairment or MCI: mild, moderate, or severe dementia);
– Mini mental status exam (MMSE) or similar test score;
– Presumptive cause (possible, probably, uncertain AD);
– Any neuropsychological testing performed;
– Results of any structural imaging (MRI, CT) performed;
– Relevant laboratory tests (B12, thyroid hormone); and,
Number and name of prescribed medications.