Effective for dates of service on or after September 15, 2004, Medicare will cover FDG PET scans for a differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer’s disease OR; its use in a CMS-approved practical clinical trial focused on the utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative diseases. Refer to Pub. 100-03, NCD Manual, section 220.6.13, for complete coverage conditions and clinical trial requirements and section 60.15 of this manual for claims processing information.
A. Carrier and FI Billing Requirements for PET Scan Claims for FDG-PET for the Differential Diagnosis of Fronto-temporal Dementia and Alzheimer’s Disease:
Procedure Code for PET Scans for Dementia and Neurodegenerative Diseases Contractors shall advise providers to use the appropriate Procedure code from section 60.3.1 for dementia and neurodegenerative diseases for services performed on or after January 28, 2005.
Diagnosis Codes for PET Scans for Dementia and Neurodegenerative Diseases
The contractor shall ensure one of the following appropriate diagnosis codes is present on claims for PET Scans for AD:
290.0, 290.10 – 290.13, 290.20 – 290, 21, 290.3, 331.0, 331.11, 331.19, 331.2, 331.9, 780.93
Medicare contractors shall use an appropriate Medicare Summary Notice (MSN) message such as 16.48, “Medicare does not pay for this item or service for this condition” to deny claims when submitted with an appropriate Procedure code from section 60.3.1 and with a diagnosis code other than the range of codes listed above. Also, contractors shall use an appropriate Remittance Advice (RA) such as 11, “The diagnosis is inconsistent with the procedure.”
Medicare contractors shall instruct providers to issue an Advanced Beneficiary Notice to beneficiaries advising them of potential financial liability prior to delivering the service if one of the appropriate diagnosis codes will not be present on the claim.