Effective for dates of service on or after September 27, 2013, contractors shall return as unprocessable/return to provider claims for PET Aß imaging, through CED during a clinical trial, not containing the following:
• Condition code 30, (A/B MAC (A) only)
• Modifier Q0 and/or modifier Q1 as appropriate
• ICD-9 dx code V70.7/ICD-10 dx code Z00.6 (on either the primary/secondary position)
• A PET HCPCS code (78811 or 78814)
• At least, one Dx code from the table below,
ICD-9 Codes Corresponding ICD-10 Codes
290.0 Senile dementia, uncomplicated F03.90 Unspecified dementia without behavioral disturbance
290.10 Presenile dementia, uncomplicated F03.90 Unspecified dementia without behavioral disturbance
290.11 Presenile dementia with delirium F03.90 Unspecified dementia without behavioral disturbance
290.12 Presenile dementia with delusional features F03.90 Unspecified dementia without behavioral disturbance
290.13 Presenile dementia with depressive features F03.90 Unspecified dementia without behavioral disturbance
290.20 Senile dementia with delusional features F03.90 Unspecified dementia without behavioral disturbance
290.21 Senile dementia with depressive features F03.90 Unspecified dementia without behavioral disturbance
290.3 Senile dementia with delirium F03.90 Unspecified dementia without behavioral disturbance
290.40 Vascular dementia, uncomplicated F01.50 Vascular dementia without behavioral disturbance
290.41 Vascular dementia with delirium F01.51 Vascular dementia with behavioral disturbance
290.42 Vascular dementia with delusions F01.51 Vascular dementia with behavioral disturbance
290.43 Vascular dementia with depressed mood F01.51 Vascular dementia with behavioral disturbance
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
294.11 Dementia in conditions classified elsewhere with
behavioral disturbance F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
294.20 Dementia, unspecified, without behavioral disturbance F03.90 Unspecified dementia without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance F03.91 Unspecified dementia with behavioral disturbance
331.11 Pick’s Disease G31.01 Pick’s disease
331.19 Other Frontotemporal dementia G31.09 Other frontotemporal dementia
331.6 Corticobasal degeneration G31.85 Corticobasal degeneration
331.82 Dementia with Lewy Bodies G31.83 Dementia with Lewy bodies
331.83 Mild cognitive impairment, so stated G31.84 Mild cognitive impairment, so stated
780.93 Memory Loss R41.1 Anterograde amnesia
R41.2 Retrograde amnesia
R41.3 Other amnesia (Amnesia NOS, Memory loss NOS)
V70.7 Examination for normal comparison or control in clinical Z00.6 Encounter for examination for normal comparison and control in clinical research program
and
• Aß HCPCS code A9586 or A9599
Contractors shall return as unprocessable claims for PET Aß imaging using the following messages:
-Claim Adjustment Reason Code 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
-Remittance Advice Remark Code N517 – Resubmit a new claim with the requested information.
– Remittance Advice Remark Code N519 – Invalid combination of HCPCS modifiers.
Contractors shall line-item deny claims for PET Aß , HCPCS code A9586 or A9599 , where a previous PET Aß, HCPCS code A9586 or A9599 is paid in history using the following messages:
• CARC 149: “Lifetime benefit maximum has been reached for this service/benefit category.”
• RARC N587: “Policy benefits have been exhausted”.
• MSN 20.12: “This service was denied because Medicare only covers this service once a lifetime.”
• Spanish Version: “Este servicio fue negado porque Medicare sólo cubre este servicio una vez en la vida.”
• Group Code: PR, if a claim is received with a GA modifier
• Group Code: CO, if a claim is received with a GZ modifier
