100-04 Medicare Claims Processing Manual: Chapter 13 - Radiology Services and Other Diagnostic Procedures

Medicare Claims Processing Manual
Chapter 13 - Radiology Services and Other Diagnostic
Procedures
Table of Contents
(Rev. 13150; Issued: 04-11-25)
Transmittals for Chapter 13
10 - ICD Coding for Diagnostic Tests
10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures
20 - Payment Conditions for Radiology Services
20.1 - Professional Component (PC)
20.2 - Technical Component (TC)
20.2.1 - Hospital and Skilled Nursing Facility (SNF) Patients
20.2.2 - Services Not Furnished in Hospitals
20.2.3 - Services Furnished in Leased Departments
20.2.4 – Services That Do Not Meet the National Electrical Manufacturers Association
(NEMA) Standard XR-29-2013
20.2.5 - Special Rule to Incentivize Transition from Traditional X-Ray Imaging to Digital
Radiography
20.2.5.1 - Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason
Codes (CARCs), and Medicare Summary Notice (MSN)
20.2.6 - Special Rule to Incentivize Transition from X-rays taken using Computed
Radiography to Digital Radiography
30 - Computerized Axial Tomography (CT) Procedures
30.1 - Low Osmolar Contrast Media (LOCM) (HCPCS Codes Q9945-Q9951)
30.1.1 - Payment Criteria
30.1.2 - Payment Level
30.1.3 - SNF Billing and A/B MAC (A) Payment for Contrast Material Other Than Low
Osmolar Contrast Material (LOCM) (Radiology)
30.1.3.1 - A/B MAC (A) Payment for Low Osmolar Contrast Material (LOCM)
(Radiology)
40 - Magnetic Resonance Imaging (MRI) Procedures
40.1 – Magnetic Resonance Angiography (MRA)
40.1.1 - Magnetic Resonance Angiography (MRA) Coverage Summary
40.1.2 - HCPCS Coding Requirements
40.1.3 - Special Billing Instructions for RHCs and FQHCs
40.1.4 - Payment Requirements
40.2 - Medicare Summary Notices (MSN), Reason Codes, and Remark Codes

50 - Nuclear Medicine (CPT 78000 - 79999)
50.1 - Payments for Radionuclides
50.2 - Stressing Agent
50.2.1 - A/B MAC (A) Payment for IV Persantine
50.2.2 - A/B MAC (A) Payment for Adenosine
50.3 - Application of Multiple Procedure Policy (CPT Modifier “-51”)
50.4 - Generation and Interpretation of Automated Data
60 - Positron Emission Tomography (PET) Scans - General Information
60.1 - Billing Instructions
60.2 - Use of Gamma Camera and Full and Partial Ring PET Scanners for PET Scans
60.2.1 - Coverage for Myocardial Viability
60.3 - PET Scan Qualifying Conditions and HCPCS Code Chart
60.3.1 - Appropriate CPT Codes Effective for PET Scans for Services Performed on or
After January 28, 2005
60.3.2 - Tracer Codes Required for Positron Emission Tomography (PET) Scans
60.3.3 - Denial Messages for Noncovered PET Services
60.4 - PET Scans for Imaging of the Perfusion of the Heart Using Rubidium 82 (Rb 82)
60.5 - Expanded Coverage of PET Scans for Solitary Pulmonary Nodules (SPNs)
60.6 - Expanded Coverage of PET Scans Effective for Services on or After July 1, 1999
60.7 - Expanded Coverage of PET Scans Effective for Services on or After July 1, 2001
60.8 - Expanded Coverage of PET Scans for Breast Cancer Effective for Dates of Service on or
After October 1, 2002
60.9 - Coverage of PET Scans for Myocardial Viability
60.10 - Coverage of PET Scans for Thyroid Cancer
60.11 -Coverage of PET Scans for Perfusion of the Heart Using Ammonia N-13
60.12 - Coverage for PET Scans for Dementia and Neurodegenerative Diseases
60.13 - Billing Requirements for PET Scans for Specific Indications of Cervical Cancer for
Services Performed on or After January 28, 2005
60.14 - Billing Requirements for PET Scans for Non-Covered Indications
60.15 - Billing Requirements for CMS - Approved Clinical Trials and Coverage With Evidence
Development Claims for PET Scans for Neurodegenerative Diseases, Previously Specified
Cancer Indications, and All Other Cancer Indications Not Previously Specified
60.16 – Billing and Coverage Changes for PET Scans
60.17 – Billing and Coverage for PET Scans for Cervical Cancer Effective for Services on or
After November 10, 2009
60.18 – Billing and Coverage Changes for PET (NaF-18) Scans to Identify Bone Metastasis of
Cancer Effective for Claims With Dates of Services on or After February 26, 2010
60.19 – Local Coverage Determination for PET Using New, Proprietary Radiopharmaceuticals
for their FDA-Approved Labeled Indications for Oncologic Imaging Only
70 - Radiation Oncology (Therapeutic Radiology)
70.1 - Weekly Radiation Therapy Management (CPT 77419 - 77430)
70.2 - Services Bundled Into Treatment Management Codes

70.3 - Radiation Treatment Delivery (CPT 77401 - 77417)
70.4 - Clinical Brachytherapy (CPT Codes 77750 - 77799)
70.5 - Radiation Physics Services (CPT Codes 77300 - 77399)
80 - Supervision and Interpretation (S&I) Codes and Interventional Radiology
80.1 - Physician Presence
80.2 - Multiple Procedure Reduction
90 - Services of Portable X-Ray Suppliers
90.1 - Professional Component
90.2 - Technical Component
90.3 - Transportation Component (HCPCS Codes R0070 - R0075)
90.3.1 – Periodic Review
90.3.2 – Annual Update
90.3.3 – Publishing Payment Rates
90.3.4 – Modifiers for Single and Multiple Patients Served at the Same Location
90.4 - Set-Up Component (HCPCS Code Q0092)
90.5 - Transportation of Equipment Billed by a SNF to a MAC
100 - Interpretation of Diagnostic Tests
100.1 - X-rays and EKGs Furnished to Emergency Room Patients
110 - Special Billing Instructions for Claims Submitted to A/B MACs (A)
110.1 - Aborted Procedure
110.2 - Combined Procedures (Radiology)
110.3 - Payment for Radiopharmaceuticals
120 - Radiology or Other Diagnostic Unlisted Service or Procedure Billing Instructions for A/B MAC
(A) Claims
130 - EMC Formats
140 - Bone Mass Measurements (BMMs)
140.1 - Payment Methodology and HCPCS Coding
140.2 - Denial Messages for Noncovered Bone Mass Measurements
140.4 - Advance Beneficiary Notices (ABNs)
150 - Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the
Technical Component (TC) of Diagnostic Tests

10 - ICD Coding for Diagnostic Tests
(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11,
2013, ICD-10: Upon Implementation of ICD-10
Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission
Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7,
2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS,
MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)
The ICD Coding Guidelines for Outpatient Services (hospital-based and physician office) have
instructed physicians to report diagnoses based on test results. Instructions and examples for coding
specialists, contractors, physicians, hospitals, and other health care providers to use in determining the
use of ICD codes for coding diagnostic test results is found in chapter 23.
10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures
(Rev. 1, 10-01-03)
Acceptable HCPCS codes for radiology and other diagnostic services are taken primarily from the CPT-
4 portion of HCPCS. Payment is the lower of the charge or the Medicare physician fee schedule
amount. Deductible and coinsurance apply, and coinsurance is based on the allowed amount.
For claims to A/B MACs (A) or (HHH), revenue codes, HCPCS code, line item dates of service, units,
and applicable HCPCS modifiers are required. Charges must be reported by HCPCS code. If the same
revenue code applies to two or more HCPCS codes, providers should repeat the revenue code and show
the line item date of service, units, and charge for each HCPCS code on a separate line.
20 - Payment Conditions for Radiology Services
(Rev. 1, 10-01-03)
B3-15022
20.1 - Professional Component (PC)
(Rev. 1, 10-01-03)
A/B MACs (B) must pay for the PC of radiology services furnished by a physician to an individual
patient in all settings under the fee schedule for physician services regardless of the specialty of the
physician who performs the service. For services furnished to hospital patients, A/B MACs (B) pay only
if the services meet the conditions for fee schedule payment and are identifiable, direct, and discrete
diagnostic or therapeutic services to an individual patient, such as an interpretation of diagnostic
procedures and the PC of therapeutic procedures. The interpretation of a diagnostic procedure includes a
written report.
20.2 - Technical Component (TC)
(Rev. 1, 10-01-03)
20.2.1 - Hospital and Skilled Nursing Facility (SNF) Patients
(Rev. 1782; Issued: 07-30-09; Effective Date: 07-01-09; Implementation Date: 07-06-09)
A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to
hospital patients. Payment for physicians’ radiological services to the hospital, e.g., administrative or
supervisory services, and for provider services needed to produce the radiology service, is made by the
AB MAC (A) to the hospital as a provider service.
AB MACs (A) include the TC of radiology services for hospital inpatients, except Critical Access
Hospitals (CAHs), in the prospective payment system (PPS) payment to hospitals.

Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for beneficiaries
in a hospital inpatient stay. CWF performs reject edits to incoming claims from suppliers of radiology
services.
Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares
the period between the hospital inpatient admission and discharge dates to the line item service date on a
line item TC of a radiology service billed by a supplier. The CWF will generate an unsolicited response
when the line item service date falls within the admission and discharge dates of the hospital inpatient
claim.
Upon receipt of an unsolicited response, the A/B MAC (B) will adjust the TC of the radiology service
and recoup the payment.
For CAHs, payment to the CAH for inpatients is made at 101 percent of reasonable cost.
Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient
Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are
submitted to the AB MAC (A). Effective 4/1/06, type of bill 14X is for non-patient laboratory
specimens and is no longer applicable for radiology services.
As a result of SNF Consolidated Billing (Section 4432(b) of the Balanced Budget Act (BBA) of 1997),
A/B MACs (B) may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF)
inpatients during a Part A covered stay. The SNF must bill radiology services furnished its inpatients in
a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS).
Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service
or by the SNF under arrangements with the supplier. If billed by the SNF, Medicare pays according to
the Medicare Physician Fee Schedule. SNFs submit claims to the AB MAC (A) with type of bill 22X or
23X.
20.2.2 - Services Not Furnished in Hospitals
(Rev. 1, 10-01-03)
A/B MACs (B) must pay under the fee schedule for the TC of radiology services furnished to
beneficiaries who are not patients of any hospital, and who receive services in a physician’s office, a
freestanding imaging or radiation oncology center, or other setting that is not part of a hospital.
20.2.3 - Services Furnished in Leased Departments
(Rev. 1, 10-01-03)
In the case of procedures furnished in a leased hospital radiology department to a beneficiary who is
neither an inpatient nor an outpatient of any hospital, e.g., the patient is referred by an outside physician
and is not registered as a hospital outpatient, both the PC and the TC of the services are payable under
the fee schedule by the A/B MAC (B).
20.2.4 – Services That Do Not Meet the National Electrical Manufacturers
Association (NEMA) Standard XR-29-2013
(Rev. 3820, Issued: 11-21-17, Effective: 01-01-18, Implementation; 01-02-18)
Section 218(a) of the Protecting Access to Medicare Act of 2014 (PAMA) is titled “Quality Incentives
To Promote Patient Safety and Public Health in Computed Tomography Diagnostic Imaging.” It
amends the Social Security Act (SSA) by reducing payment for the technical component (and the
technical component of the global fee) of the Physician Fee Schedule service (5 percent in 2016 and 15
percent in 2017 and subsequent years) for computed tomography (CT) services identified by CPT codes

70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178,
74261-74263, and 75571-75574 furnished using equipment that does not meet each of the attributes of
the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013, entitled “Standard
Attributes on CT Equipment Related to Dose Optimization and Management.”
The statutory provision requires that information be provided and attested to by a supplier and a hospital
outpatient department that indicates whether an applicable CT service was furnished that was not
consistent with the NEMA CT equipment standard, and that such information may be included on a
claim and may be a modifier. The statutory provision also provides that such information shall be
verified, as appropriate, as part of the periodic accreditation of suppliers under SSA section 1834(e) and
hospitals under SSA section 1865(a). Any reduced expenditures resulting from this provision are not
budget neutral. To implement this provision, CMS created modifier “CT” (Computed tomography
services furnished using equipment that does not meet each of the attributes of the National Electrical
Manufacturers Association (NEMA) XR-29-2013 standard).
Beginning in 2016, claims for CT scans described by above-listed CPT codes (and any successor codes)
that are furnished on non-NEMA Standard XR-29-2013-compliant CT scans must include modifier
“CT” that will result in the applicable payment reduction.
A list of codes subject to the CT modifier will be maintained in the web supporting files for the annual
rule.
Beginning January 1, 2016, a payment reduction of 5 percent applies to the technical component (and
the technical component of the global fee) for Computed Tomography (CT) services furnished using
equipment that is inconsistent with the CT equipment standard and for which payment is made under the
physician fee schedule. This payment reduction becomes 15 percent beginning January 1, 2017, and
after.
20.2.5 - Special Rule to Incentivize Transition from Traditional X-Ray Imaging to
Digital Radiography
(Rev.3820, Issued: 11-21-17, Effective: 01-01-18, Implementation; 01-02-18)
Section 502(a)(1) of the Consolidated Appropriations Act of 2016 is titled "Medicare Payment Incentive
for the Transition from Traditional X-Ray Imaging to Digital Radiography and Other Medicare Imaging
Payment Provision." It amends the Social Security Act (SSA) by reducing the payment amounts under
the Physician Fee Schedule by 20 percent for the technical component (and the technical component of
the global fee) of imaging services that are X-rays taken using film, effective January 1, 2017, and after.
Modifier FX (X ray taken using film) was created to implement this provision. Beginning January 1,
2017, claims for X-rays using film must include modifier FX, which will result in the applicable
payment reduction.
20.2.5.1 - Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason
Codes (CARCs), and Medicare Summary Notice (MSN)
(Rev.3820, Issued: 11-21-17, Effective: 01-01-18, Implementation; 01-02-18)
Contractors shall use the following messages when adjusting x-ray radiograph claim lines that have been
reported with the FX modifier:
CARC 237 – Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be
comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an
ALERT.)

RARC N775 - Payment adjusted based on x-ray radiograph on film.
MSN 30.1 - The approved amount is based on a special payment method.
20.2.6 - Special Rule to Incentivize Transition from X-rays taken using Computed
Radiography to Digital Radiography
(Rev. 3820, Issued: 11-21-17, Effective: 01-01-18, Implementation; 01-02-18)
1848 (b)(9) of the Social Security Act provides that payments for imaging services that are X-rays taken
using computed radiography (including the X-ray component of a packaged service) furnished during
CY 2018, 2019, 2020, 2021, or 2022, that would otherwise be made under the PFS (without application
of subparagraph (B)(i) and before application of any other adjustment), be reduced by 7 percent, and
similarly, if such X-ray services are furnished during CY 2023 or a subsequent year, by 10 percent.
Computed radiography technology is defined for purposes of this paragraph as cassette-based imaging
which utilizes an imaging plate to create the image involved.
Modifier FY was created to implement this provision. Beginning January 1, 2018, claims for computed
radiography must include modifier FY, which will result in the applicable payment reduction.
20.3 – Anti-Markup Payment Limitation
(Rev. 1931, Issued: 03-12-10, Effective: 06-14-10, Implementation: 06-14-10)
Section 1842(n)(1) of the Social Security Act (the Act) establishes payment rules for certain diagnostic
tests (other than clinical diagnostic laboratory tests) where the physician performing or supervising the
test does not share a practice with the billing physician or other supplier. Examples of tests covered
under this rule include, but are not limited to: x-rays, EKGs, EEGs, cardiac monitoring, and ultrasound
services furnished on or after January 1, 1994. (Note that screening mammography services are covered
under another provision of the Act and are not subject to the anti-markup payment limitation.) The anti-
markup payment limitation applies to the technical component or “TC” of certain diagnostic tests that
are payable on the Medicare Physician Fee Schedule (MPFS). Effective January 1, 2009, the anti-
markup payment limitation also applies to the professional component or (“PC”) of diagnostic tests
(other than clinical diagnostic tests). The anti-markup payment limitation only applies when a physician
(or other supplier) orders and bills for a diagnostic test in which the TC or PC is performed by a
physician who does not “share a practice” with the ordering/billing physician (or other supplier). For
more information on the anti-markup payment limitation, see chapter 1, §30.2.9.
20.3.1 – A/B MAC (B) Payment Rules
(Rev. 1931, Issued: 03-12-10, Effective: 06-14-10, Implementation: 06-14-10)
If a diagnostic test (other than a clinical diagnostic laboratory test) is personally performed or is
supervised by a physician, such physician may bill under the normal physician fee schedule rules. This
includes situations in which the test is performed or supervised by another physician with whom the
billing physician shares a practice (see Pub. 100-04, chapter 1, §30.2.9). Section 80, chapter 15, of Pub.
100-02, Medicare Benefit Policy, sets forth the various levels of physician supervision required for
diagnostic tests. The supervision requirement for physician billing is not met when the test is
administered by supplier personnel regardless of whether the test is performed at the physician's office
or at another location.
If a physician bills for a diagnostic test that is subject to the anti-markup payment limitation, the fee
schedule amount for the acquired service equals the lower of:

• 	The performing physician or other supplier’s net charge to the billing physician or other supplier
for performing the service;
• 	The billing physician or other supplier’s actual charge; or
• 	The fee schedule amount allowed for the jurisdiction where the service was performed.
The lowest figure is the fee schedule amount for purposes of the limiting charge. (See chapter 1,
§30.3.12.1 of this publication) The billing entity must identify the performing physician or other
supplier (including the performing provider’s NPI) and the amount the performing physician or other
supplier charged the billing entity (net of any discounts). A physician who accepts assignment is
permitted to bill and collect from the beneficiary only the applicable deductible and coinsurance for the
acquired test. A physician who does not accept assignment is permitted to bill and collect from the
beneficiary only the fee schedule amount (as defined above) for the acquired test. The limiting charge
provision is not applicable.
If the physician does not identify who performed the test and provide the other required information, no
payment is allowed. The physician may not bill the beneficiary any amount for the test.
20.3.2 - Billing for Services
(Rev. 1931, Issued: 03-12-10, Effective: 06-14-10, Implementation: 06-14-10)
A physician or other supplier may bill and receive Part B payment for the technical component (TC) or
professional component (PC) of diagnostic tests which the physician or other supplier contracts a
physician, medical group, or other supplier to perform. (This claim and payment procedure does not
extend to clinical diagnostic laboratory tests.) The anti-markup rule will apply to the TC or PC of
diagnostic tests that have been ordered by the billing physician or other supplier (or by a party
financially related to the billing physician or other supplier through common ownership or control) if the
performing physician or other supplier does not meet the criteria for “sharing a practice” with the
ordering/billing entity. An example is when the attending physician orders radiology tests from a
radiologist and the radiologist purchases the tests from an imaging center with whom the radiologist
does not meet the criteria for “sharing a practice.” Under the anti-markup payment limitation, the billing
physician or other supplier may not mark up the charge for a test from the acquisition price and must
accept as full payment for the test (even if assignment is not accepted) the lowest of: the fee schedule
amount as if the performing physician or other supplier had billed directly, the billing entity’s actual
charge, or the performing physician or other supplier’s net charge to the billing entity. The billing
physician or other supplier must be financially related to the physician or group that ordered the tests
through common ownership or control.
If the performing physician or other supplier meets the criteria for “sharing a practice” with the billing
physician or other supplier, then the anti-markup payment limitation will not apply and the lower of the
physician fee schedule amount or the billed amount will be paid.
The physician or other supplier that performed the component that is subject to the anti-markup rule
must be enrolled in the Medicare program. No formal reassignment is necessary; however, reassigned
services are also subject to the anti-markup payment limitation.
A. Radiology Services
Contractors shall apply the anti-markup payment limitation to the TC and PC of radiology diagnostic
testing services other than screening mammography procedures. See Publication 100-04, chapter 1,
§30.2.9 for more information on the anti-markup payment limitation.
B. Payment to a Physician or Other Supplier of Diagnostic Tests for Services Subject to the Anti-
Markup Payment Limitation

A physician or other supplier that provides diagnostic tests may bill and receive the Part B payment for
the TC or PC of diagnostic tests which that physician or other supplier acquires from another physician,
medical group, or other supplier. If the performing physician does not meet the requirements for sharing
a practice with the ordering/billing physician or other supplier, then the anti-markup payment limitation
rules will apply. (See section 30.2.9 of this chapter for more information.) If the performing physician is
deemed to share a practice with the physician or other supplier that ordered the test, then the physician
fee schedule amount may be billed and the anti-markup payment limitation will not apply. In either
case, the performing physician or other supplier must be enrolled in the Medicare program. No formal
reassignment is necessary; however, the anti-markup payment limitation will apply to reassigned
services.
If the anti-markup rules apply, payment may not exceed the lowest of the following amounts:
• 	The performing physician or other supplier’s net charge to the billing physician or other
supplier;*
• 	The billing physician or other supplier’s actual charges; or
• 	The fee schedule amount allowed for the test if the performing physician or other supplier billed
directly.
*The net charge must be determined without regard to any charge that is intended to reflect the cost of
equipment or space leased to the performing physician or supplier by or through the billing entity. For
more information, see Pub. 100-04, chapter 1, §30.2.9.
The billing physician or other supplier must keep on file the name, address, and NPI of the physician or
other supplier who performed the anti-markup service.
C. Sanctions
Physicians who knowingly and willfully, in repeated cases, bill Medicare beneficiaries amounts beyond
those outlined in this chapter are subject to the penalties contained under §1842(j)(2) of the Act.
Penalties are assigned after post-pay review depending on the severity.
D. Questionable Business Arrangements
No special charge or payment constraints are imposed on tests performed by a physician or a technician
under the physician’s supervision. There are two requirements for all diagnostic tests under §1861(s)(3)
of the Act, as implemented by 42 CFR §410.32 and section 10 of chapter13 of this publication and
section 80, chapter 15 of Pub. 100-02BP. Namely, the test must be ordered by the treating practitioner,
and the test must be supervised by a physician. However, attempts may be made by the medical
diagnostic community to adjust or establish arrangements which continue to allow physicians to profit
from other's work or by creating the appearance that the physician has performed or supervised his/her
technicians who are employed, contracted, or leased. Some of these arrangements may involve cardiac
scanning services and mobile ultrasound companies leasing their equipment to physicians for the day the
equipment is used, and hiring out their staff to the physicians to meet the supervision requirement.
The bona fides of such arrangements may be suspect and could be an attempt to circumvent the anti-
markup payment limitation. If you have any doubt that a particular arrangement is a valid relationship
where the physician is performing or supervising the services, this should be investigated. The Office of
the Inspector General (OIG) has responsibility for investigating violations of §1842(n) of the Act.
Another arrangement to circumvent the anti-markup payment limitation is for the ordering physician to
reassign his/her payment for the interpretation of the test to the supplier. The supplier, in turn, bills for
both the test and the interpretation and pays the ordering physician a fee for the interpretation. This
arrangement violates §1842(b)(6) of the Act, which prohibits Medicare from paying benefits due the
person that furnished the service to any other person, subject to limited exceptions discussed in Pub.

100-04, chapter 1, §30.2.2. Also, this arrangement could constitute a violation of §1128 B (b) of the
Act, which prohibits remuneration for referrals (i.e., kickbacks).
Violations of §1128B (b) of the Act may subject the physician or supplier to criminal penalties or
exclusion from the Medicare and Medicaid programs. Illegal remuneration for referrals can be found
even when the ordering physician performs some service for the remuneration.
30 - Computerized Axial Tomography (CT) Procedures
(Rev. 1, 10-01-03)
A/B MACs (B) do not reduce or deny payment for medically necessary multiple CT scans of different
areas of the body that are performed on the same day.
The TC RVUs for CT procedures that specify “with contrast” include payment for high osmolar contrast
media. When separate payment is made for low osmolar contrast media under the conditions set forth in
§30.1.1, reduce payment for the contrast media as set forth in §30.1.2.
30.1 - Low Osmolar Contrast Media (LOCM) (HCPCS Codes Q9945-Q9951)
(Rev. 627, Issued: 07-29-05, Effective: 01-01-05, Implementation: 10-31-05)
HCPCS codes A4644-A4646 have been replaced with Q9945-Q0051.
30.1.1 - Payment Criteria
(Rev. 627, Issued: 07-29-05, Effective: 01-01-05, Implementation: 10-31-05)
A/B MACs (B) make separate payments for LOCM (HCPCS codes Q9945-Q9951) in the case of all
medically necessary intrathecal radiologic procedures furnished to nonhospital patients. Effective
January 1, 2005 in the case of intraarterial and intravenous radiologic procedures, the five restrictive
criteria (a history of previous adverse reaction to contrast material, with the exception of a sensation of
heat, flushing, or a single episode of nausea or vomiting; a history of asthma or allergy; significant
cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable
angina pectoris, recent myocardial infarction, and pulmonary hypertension; generalized severe
debilitation; or sickle cell disease) for the payment of LOCM are eliminated.
30.1.2 - Payment Level
(Rev. 627, Issued: 07-29-05, Effective: 01-01-05, Implementation: 10-31-05)
Determine payment in the same manner as for a drug furnished incident to a physician’s service.
The payment methodology for LOCM for the period of January 1, 2005 through March 31, 2005 is made
in accordance with the established payment for calendar year 2004 using codes A4644-A4646.
Effective April 1, 2005, the method of payment for LOCM is the average sales price (ASP) plus six
percent in accordance with the standard methodology for drug pricing established by the Medicare
Modernization Act (MMA0 for other than hospital outpatient claims. Payments for the new Q codes can
be found in the respective quarterly Medicare Part B drug pricing files that are posted on the CMS Web
site.
30.1.3 - SNF Billing and A/B MAC (A) Payment for Contrast Material Other Than
Low Osmolar Contrast Material (LOCM) (Radiology)
(Rev. 1, 10-01-03)
When a radiology procedure is provided with contrast material, a SNF should bill using the CPT-4 code
that indicates “with” contrast material. If the coding does not distinguish between “with” and “without”
contrast material, the SNF should use the available code.

Contrast material other than LOCM may be billed separately in addition to the radiology procedure, or it
may be billed as part of the amount for the radiology procedure. If the SNF bills separately for the
contrast material and the charge for the procedure includes a charge for contrast material, the SNF must
adjust the charge for the procedure to exclude any amount for the contrast material. Regardless of the
billing method used, charges are subject to the fee schedule.
When billing separately for this contrast material, the SNF should use revenue code 0255 (drugs incident
to radiology and subject to the payment limit) and report the charge on the same bill as the radiology
procedure. The A/B MAC (A) will not accept late charge bills for this service.
30.1.3.1 - A/B MAC (A) Payment for Low Osmolar Contrast Material (LOCM)
(Radiology)
(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11,
2013, ICD-10: Upon Implementation of ICD-10
Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission
Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7,
2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS,
MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)
The LOCM is paid on a reasonable cost basis when rendered by a SNF to its Part B patients (in addition
to payment for the radiology procedure) when it is used in one of the situations listed below.
The following HCPCS are used when billing for LOCM.
HCPCS Code 	Description (January 1. 1994, and later)
A4644 	Supply of low osmolar contrast material (100-199 mgs of iodine);
A4645 	Supply of low osmolar contrast material (200-299 mgs of iodine); or
A4646 	Supply of low osmolar contrast material (300-399 mgs of iodine).
When billing for LOCM, SNFs use revenue code 0636. If the SNF charge for the radiology procedure
includes a charge for contrast material, the SNF must adjust the charge for the radiology procedure to
exclude any amount for the contrast material.
NOTE: LOCM is never billed with revenue code 0255 or as part of the radiology procedure.
The A/B MAC (A) will edit for the intrathecal procedure codes and the following codes to determine if
payment for LOCM is to be made. If an intrathecal procedure code is not present, or one of the ICD
codes is not present to indicate that a required medical condition is met, the A/B MAC (A) will deny
payment for LOCM. In these instances, LOCM is not covered and should not be billed to Medicare.
When LOCM Is Separately Billable and Related Coding Requirements
• 	In all intrathecal injections. HCPCS codes that indicate intrathecal injections are:
70010 	70015 	72240 	72255 	72265 	72270 	72285 	72295
One of these must be included on the claim; or
• 	In intravenous and intra-arterial injections only when certain medical conditions are present in an
outpatient. The SNF must verify the existence of at least one of the following medical
conditions, and report the applicable diagnosis code(s) either as a principal diagnosis code or
other diagnosis codes on the claim:
o 	A history of previous adverse reaction to contrast material. The applicable ICD-9-CM codes
are V14.8 and V14.9. The applicable ICD-10-CM codes are Z88.8 and Z88.9. The

conditions which should not be considered adverse reactions are a sensation of heat, flushing,
or a single episode of nausea or vomiting. If the adverse reaction occurs on that visit with the
induction of contrast material, codes describing hives, urticaria, etc. should also be present, as
well as a code describing the external cause of injury and poisoning, ICD-9-CM code E947.8.
The applicable ICD-10 CM codes are: T50.8X5A Adverse effect of diagnostic agents, initial
encounter, T50.8X5S Adverse effect of diagnostic agents, sequela , T50.995A Adverse effect
of other drugs, medicaments and biological substances, initial encounter, or T50.995S
Adverse effect of other drugs, medicaments and biological substances, sequela;
o 	A history or condition of asthma or allergy. The applicable ICD-9-CM codes are V07.1,
V14.0 through V14.9, V15.0, 493.00, 493.01, 493.10, 493.11, 493.20, 493.21, 493.90,
493.91, 495.0, 495.1, 495.2, 495.3, 495.4, 495.5, 495.6, 495.7, 495.8, 495.9, 995.0, 995.1,
995.2, and 995.3. The applicable ICD-10-CM codes are in the table below:
ICD-10-CM Codes
J44.0 	J44.9 	J45.20 	J45.22 	J45.30 	J45.32 	J45.40
J45.42 	J45.50 	J45.52 	J45.902 	J45.909 	J45.998 	J67.0
J67.1 	JJ67.2 	J67.3 	J67.4 	J67.5 	J67.6 	J67.7
J67.8 	J67.9 	J96.00 	J96.01 	J96.02 	J96.90 	J96.91
J96.92 	T36.0X5A 	T36.1X5A 	T36.2X5A 	T36.3X5A 	T36.4X5A 	T36.5X5A
T36. 6X5A 	T36.7X5A 	T36.8X5A 	T36.95XA 	T37.0X5A 	T37.1X5A 	T37.2X5A
T37.3X5A 	T37.8X5A 	T37.95XA 	T38.0X5A 	T38.1X5A 	T38.2X5A 	T38.3X5A
T38.4X5A 	T38.6X5A 	T38.7X5A 	T38.805A 	T38.815A 	T38.895A 	T38.905A
T38.995A 	T39.015A 	T39.095A 	T39.1X5A 	T39.2X5A 	T39.2X5A 	T39.315A
T39.395A 	T39.4X5A 	T39.8X5A 	T39.95XA 	T40.0X5A 	T40.1X5A 	T40.2X5A
T40.3X5A 	T40.4X5A 	T40.5X5A 	T40.605A 	T40.695A 	T40.7X5A 	T40.8X5A
T40.905A 	T40.995A 	T41.0X5A 	T41.1X5A 	T41.205A 	T41.295A 	T41.3X5A
T41.4X5A 	T41.X5A 	T41.5X5A 	T42.0X5A 	T42.1X5A 	T42.2X5A 	T42.3X5A
T42.4X5A 	T42.5X5A 	T42.6X5A 	427.5XA 	428.X5A 	T43.015A 	T43.025A
T43.1X5A 	T43.205A 	T43.215A 	T43.225A 	T43.295A 	T43.3X5A 	T43.4X5A
T43.505A 	T43.595A 	T43.605A 	T43.615A 	T43.625A 	T43.635A 	T43.695A
T43.8X5A 	T43.95XA 	T44.0X5A 	T44.1X5A 	T44.2X5A 	T44.3X5A 	T44.6X5A
T44.7X5A 	T44.8X5A 	T44.905A 	T44.995A 	T45.0X5A 	T45.1X5A 	T45.2X5A
T45.3X5A 	T45.4X5A 	T45.515A 	T45.525A 	T45.605A 	T45.615A 	T45.625A
T45.695A 	T45.7X5A 	T45.8X5A 	T45.95XA 	T46.0X5A 	T46.1X5A 	T46.2X5A
T46.3X5A 	T46.4X5A 	T46.5X5A 	T46.6X5A 	T46.7X5A 	T46.8X5A 	T46.905A
T46.995A 	T47.0X5A 	T47.1X5A 	T47.2X5A 	T47.3X5A 	T47.4X5A 	T47.5X5A
T47.6X5A 	T47.7X5A 	T47.8X5A 	T47.95XA 	T48.0X5A 	T48.1X5A 	T48.205A
T48.295A 	T48.3X5A 	T48.4X5A 	T48.5X5A 	T48.6X5A 	T48.905A 	T48.995A
T49.0X5A 	T49.1X5A 	T49.2X5A 	T49.3X5A 	T49.4X5A 	T49.5X5A 	T49.6X5A
T49.6X5A 	T47.X5A9 	T49.8X5A 	T49.95XA 	T50.0X5A 	T50.1X5A 	T50.2X5A
T50.3X5A 	T50.4X5A 	T50.5X5A 	T50.6X5A 	T50.7X5A 	T50.8X5A 	T50.905a
T50.995A 	T50.A15A 	T50.A25A 	T50.A95A 	T50.B15A 	T50.B95A 	T50.Z15A
T50.Z95A 	T78.2XXA 	T78.3XXA 	T78.40XA 	T78.41XA 	T88.52XA 	T88.59XA
T88.6XXA 	Z51.89 	Z88.0 	Z88.1 	Z88.2 	Z88.3 	Z88.4
Z88.5 	Z88.6 	Z88.7 	Z88.8 	Z88.9 	Z91.010
o 	Significant cardiac dysfunction including recent or imminent cardiac decompensation,
severe arrhythmia, unstable angina pectoris, recent myocardial infarction, and pulmonary
hypertension. The applicable ICD-9-CM codes are:
ICD-9-CM
402.00 	402.01 	402.10 	402.11 	402.90 	402.91
404.00 	404.01 	404.02 	404.03
404.10 	404.11 	404.12 	404.13
404.90 	404.91 	404.92 	404.93
410.00 	410.01 	410.02 	410.10 	410.11 	410.12
410.20 	410.21 	410.22 	410.30 	410.31 	410.32

ICD-9-CM
410.40 	410.41 	410.42 	410.50 	410.51 	410.52
410.60 	410.61 	410.62 	410.70 	410.71 	410.72
410.80 	410.81 	410.82 	410.90 	410.91 	410.92
411.1 	415.0 	416.0 	416.1 	416.8 	416.9
420.0 	420.90 	420.91 	420.99 	424.90 	424.91
424.99 	427.0 	427.1 	427.2 	427.31 	427.32
427.41 	427.42 	427.5 	427.60 	427.61 	427.69
427.81 	427.89 	427.9 	428.0 	428.1 	428.9 	429.0
429.1 	429.2 	429.3 	429.4 	429.5 	429.6 	429.71
429.79 	429.81 	429.82 	429.89 	429.9 	785.50 	785.51 	785.59
o 	The applicable ICD-10-CM codes are in the table below:
ICD-10-CM Codes
A18.84 	I11.0 	I11.9 	I13.0 	I13.10 	I13.11 	I13.2
I20.0 	I21.01 	I21.02 	I21.09 	I21.11 	I21.19 	I21.21
I21.29 	I21.3 	I21.4 	I22.1 	I22.2 	I22.8 	I23.0
I23.1 	I23.2 	I23.3 	I23.4 	I23.5 	I23.6 	I23.7
I23.8 	I25.10 	I25.110 	I25.700 	I25.710 	I25.720 	I25.730
I25.750 	I25.760 	I25.790 	I26.01 	I26.02 	I26.09 	I27.0
I27.1 	I27.2 	I27.81 	I27.89 	I27.9 	I30.0 	I30.1
I30.8 	I30.9 	I32 	I38 	I39 	I46.2 	I46.8
I46.9 	I47.0 	I471 	I472 	I47.9 	I48.0 	I48.1
I48.1 	I48.2 	I48.3 	I48.4 	I48.91 	I48.92 	I49.01
I49.02 	I49.1 	I49.2 	I49.3 	I49.40 	I49.49 	I49.5
I49.8 	I49.9 	I50.1 	I50.20 	I50.21 	I50.22 	I50.23
I50.30 	I50.31 	I50.32 	I50.33 	I50.40 	I50.41 	I50.42
I50.43 	I50.9 	I51 	I51.0 	I51.1 	I51.2 	I51.3
I51.4 	I51.5 	I51.7 	I51.89 	I51.9 	I52 	I97.0
I97.110 	I97.111 	I97.120 	I97.121 	I97.130 	I97.131 	I97.190
I97.191 	M32.11 	M32.12 	R00.1 	R57.0 	R57.8 	R57.9
o 	Generalized severe debilitation. The applicable ICD-9-CM codes are: 203.00, 203.01, all
codes for diabetes mellitus, 518.81, 585, 586, 799.3, 799.4, and V46.1. The applicable
ICD-10-CM codes are: J96.850, J96.00 through J96.02, J96.90 through J96.91, N18.1
through N19, R53.81, R64, and Z99.11 through Z99.12. Or
o 	Sickle Cell disease. The applicable ICD-9-CM codes are 282.4, 282.60, 282.61, 282.62,
282.63, and 282.69. The applicable ICD-10-CM codes are D56.0 through D56.3, D56.5
through D56.9, D57.00 through D57.1, D57.20, D57.411 through D57.419, and D57.811
through D57.819.
40 - Magnetic Resonance Imaging (MRI) Procedures
(Rev. 2307, Issued: 09-22-11, Effective: 07-07-11/02-24-11(CR 7296), Implementation: 09-26-11)
Effective September 28, 2009
The Centers for Medicare & Medicaid Services (CMS) finds that the non-coverage of magnetic
resonance imaging (MRI) for blood flow determination is no longer supported by the available evidence.
CMS is removing the phrase “blood flow measurement” and local Medicare contractors will have the
discretion to cover (or not cover).
Consult Publication (Pub.) 100-03, National Coverage Determinations (NCD) Manual, chapter 1, section
220.2, for specific coverage and non-coverage indications associated with MRI and MRA (Magnetic
Resonance Angiography).

Prior to January 1, 2007
A/B MACs (B) do not make additional payments for three or more MRI sequences. The relative value
units (RVUs) reflect payment levels for two sequences.
The technical component (TC) RVUs for MRI procedures that specify “with contrast” include payment
for paramagnetic contrast media. A/B MACs (B) do not make separate payment under code A4647.
A diagnostic technique has been developed under which an MRI of the brain or spine is first performed
without contrast material, then another MRI is performed with a standard (0.1mmol/kg) dose of contrast
material and, based on the need to achieve a better image, a third MRI is performed with an additional
double dosage (0.2mmol/kg) of contrast material. When the high-dose contrast technique is utilized,
A/B MACs (B):
• 	Do not pay separately for the contrast material used in the second MRI procedure;
• 	Pay for the contrast material given for the third MRI procedure through supply code Q9952, the
replacement code for A4643, when billed with Current Procedural Terminology (CPT) codes
70553, 72156, 72157, and 72158;
• 	Do not pay for the third MRI procedure. For example, in the case of an MRI of the brain, if CPT
code 70553 (without contrast material, followed by with contrast material(s) and further
sequences) is billed, make no payment for CPT code 70551 (without contrast material(s)), the
additional procedure given for the purpose of administering the double dosage, furnished during
the same session. Medicare does not pay for the third procedure (as distinguished from the
contrast material) because the CPT definition of code 70553 includes all further sequences; and
• 	Do not apply the payment criteria for low osmolar contrast media in §30.1.2 to billings for code
Q9952, the replacement code for A4643.
Effective January 1, 2007
With the implementation for calendar year 2007 of a bottom-up methodology, which utilizes the direct
inputs to determine the practice expense (PE) relative value units (RVUs), the cost of the contrast media
is not included in the PE RVUs. Therefore, a separate payment for the contrast media used in various
imaging procedures is paid. In addition to the CPT code representing the imaging procedure, separately
bill the appropriate HCPCS “Q” code (Q9945 – Q9954; Q9958-Q9964) for the contrast medium utilized
in performing the service.
Effective February 24, 2011
Medicare will allow for coverage of MRI for beneficiaries with implanted PMs or cardioverter
defibrillators (ICDs) for use in an MRI environment in a Medicare-approved clinical study as described
in section 220.C.1 of the NCD manual.
Effective July 7, 2011
Medicare will allow for coverage of MRI for beneficiaries with implanted pacemakers (PMs) when the
PMs are used according to the Food and Drug Administration (FDA)-approved labeling for use in an
MRI environment as described in section 220.2.C.1 of the NCD Manual.
40.1 – Magnetic Resonance Angiography (MRA)
(Rev. 2171, Issued: 03-04-11, Effective: 02-24-11, Implementation: 04-04-11)
40.1.1 – Magnetic Resonance Angiography (MRA) Coverage Summary

(Rev. 2171, Issued: 03-04-11, Effective: 02-24-11, Implementation: 04-04-11)
Section 1861(s)(2)(C) of the Social Security Act provides for coverage of diagnostic testing. Coverage
of magnetic resonance angiography (MRA) of the head and neck, and MRA of the peripheral vessels of
the lower extremities is limited as described in Publication (Pub.) 100-03, the Medicare National
Coverage Determinations (NCD) Manual. This instruction has been revised as of July 1, 2003, based on
a determination that coverage is reasonable and necessary in additional circumstances. Under that
instruction, MRA is generally covered only to the extent that it is used as a substitute for contrast
angiography, except to the extent that there are documented circumstances consistent with that
instruction that demonstrates the medical necessity of both tests. Prior to June 3, 2010, there was no
coverage of MRA outside of the indications and circumstances described in that instruction.
Effective for claims with dates of service on or after June 3, 2010, contractors have the discretion to
cover or not cover all indications of MRA (and magnetic resonance imaging (MRI)) that are not
specifically nationally covered or nationally non-covered as stated in section 220.2 of the NCD Manual.
Because the status codes for HCPCS codes 71555, 71555-TC, 71555-26, 74185, 74185-TC, and 74185-
26 were changed in the Medicare Physician Fee Schedule Database from ‘N’ to ‘R’ on April 1, 1998,
any MRA claims with those HCPCS codes with dates of service between April 1, 1998, and June 30,
1999, are to be processed according to the contractor’s discretionary authority to determine payment in
the absence of national policy.
Effective for claims with dates of service on or after February 24, 201l, Medicare will provide coverage
for MRIs for beneficiaries with implanted cardiac pacemakers or implantable cardioverter defibrillators
if the beneficiary is enrolled in an approved clinical study under the Coverage with Study Participation
form of Coverage with Evidence Development that meets specific criteria per Pub. 100-03, the NCD
Manual, chapter 1, section 220.2.C.1.
40.1.2 - HCPCS Coding Requirements
(Rev. 1472, Issued: 03-06-08, Effective: 05-23-07, Implementation: 04-07-08)
Providers must report HCPCS codes when submitting claims for MRA of the chest, abdomen, head,
neck or peripheral vessels of lower extremities. The following HCPCS codes should be used to report
these services:
MRA 	Code
MRA of head 	70544, 70544-26, 70544-TC
MRA of head 	70545, 70545-26, 70545-TC
MRA of head 	70546, 70546-26, 70546-TC
MRA of neck 	70547, 70547-26, 70547-TC
MRA of neck 	70548, 70548-26, 70548-TC
MRA of neck 	70549, 70549-26, 70549-TC
MRA of chest 	71555, 71555-26, 71555-TC
MRA of pelvis 	72198, 72198-26, 72198-TC
MRA of abdomen (dates of service on or
after July 1, 2003) – see below.
74185, 74185-26, 74185-TC

MRA of peripheral vessels of lower
extremities
73725, 73725-26, 73725-TC
Hospitals subject to OPPS should report the following C codes in place of the above HCPCS codes as
follows:
• 	MRA of chest 71555: C8909 – C8911
• 	MRA of abdomen 74185: C8900 – C8902
• 	MRA of peripheral vessels of lower extremities 73725: C8912 – C8914
For claims with dates of service on or after July 1, 2003, coverage under this benefit has been expanded
for the use of MRA for diagnosing pathology in the renal or aortoiliac arteries. The following HCPCS
code should be used to report this expanded coverage of MRA:
• 	MRA, pelvis, with or without contrast material(s) 72198, 72198-26, 72198-TC
Hospitals subject to OPPS report the following C codes in place of HCPCS code 72198:
• 	MRA, pelvis, with or without contrast material(s) 72198: C8918 - C8920
NOTE: Information regarding the claim form locator that corresponds to the HCPCS code and a table
to crosswalk its CMS-1450 form locator to the 837 transaction is found in Chapter 25.
40.1.3 - Special Billing Instructions for RHCs and FQHCs
(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11,
2013, ICD-10: Upon Implementation of ICD-10
Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission
Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7,
2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS,
MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)
Independent RHCs and free-standing FQHCs bill under bill type 71X and 73X for the professional
component utilizing revenue codes 520 and 521 as appropriate. HCPCS coding is not required. The
technical component is outside the scope of the RHC/FQHC benefit. The provider of the technical
service bills using the ASC X12 837 professional claim format or on Form CMS-1500.
The technical component for a provider based RHC/FQHC is typically furnished by the provider. The
provider of that service bills under bill type 13X or 85X as appropriate using its outpatient provider
number (not the RHC/FQHC provider number since these services are not covered as RHC/FQHC
services). Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer
applicable for radiology services.
40.1.4 – Payment Requirements
(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11,
2013, ICD-10: Upon Implementation of ICD-10
Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission
Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7,
2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS,
MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)
For claims with dates of service on and after February 24, 2011, the following diagnosis code and
modifier shall be reported on MRI claims for beneficiaries with implanted PMs, that are outside FDA-
approved labeling for use in an MRI environment (in a Medicare-approved clinical study):

• 	Appropriate MRI code
• 	Q0 modifier
• 	Condition code 30 (for institutional claims)
• 	If ICD-9-CM is applicable
o 	ICD-9 code V70.7- Examination of participant in clinical trial (for institutional claims)
o 	ICD-9 code V45.02 (automatic implantable cardiac defibrillator) or
o 	ICD-9 code V45.01 (cardiac pacemaker)
• 	If ICD-10-CM is applicable
• 	Z00.6 - Encounter for examination for normal comparison and control in clinical research
program
• 	Z95.810 - Presence of automatic (implantable) cardiac defibrillator or
• 	Z95.0 - Presence of cardiac pacemaker
For claims with dates of services on and after July 7, 2011, the following codes shall be reported on MRI
claims for beneficiaries with implanted PMs that have FDA-approved labeling for use in an MRI
environment:
• 	Appropriate MRI code
• 	KX modifier
• 	If ICD-9-CM is applicable
o 	ICD-9 code V45.01 (cardiac pacemaker)
• 	If ICD-10-CM is applicable
o 	ICD-10 code Z95.0 (cardiac pacemaker)
Payment is as follows:
• 	Professional claims (practitioners and suppliers) - based on the Medicare Physician Fee
Schedule (MPFS)
• 	Inpatient (11x) - Prospective payment system (PPS), based on the diagnosis-related group
• 	Hospital outpatient departments (13x) - Outpatient PPS, based on the ambulatory payment
classification
• 	Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) (71x/77x) - All-
inclusive rate, professional component only, based on the visit furnished to the RHC/FQHC
beneficiary to receive the MRI. The technical component is outside the scope of the RHC/FQHC
benefit. Therefore the provider of the technical service bills their A/B MAC (B) on the ASC X12
837 professional claim format or hardcopy Form CMS-1500 and payment is made under the
MPFS.
• 	Critical access hospitals (CAHs) (85x) –
o 	For CAHs that elected the optional method of payment for outpatient services, the
payment for technical services would be the same as the CAHs that did not elect the
optional method - Reasonable cost.
o 	The A/B MAC (A) pays the professional component at 115% of the MPFS.
Deductible and coinsurance apply.
40.2 – Medicare Summary Notices (MSN), Reason Codes, and Remark Codes
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17)
The A/B MAC denies MRI line items on claims when billed with the appropriate MRI code and a

diagnostic code for cardiac pacemaker if modifier KX is not present.
The contractor shall use the following remittance advice messages and associated codes when
rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH
CORE Business Scenario Three.
Group Code: CO
CARC: 188
RARC: N/A
MSN: 21.8
The A/B MAC denies MRI line items that do not include all of the following line items:
• 	An appropriate MRI code,
• 	If ICD-9-CM is applicable, ICD-9 code V45.02 (automatic implantable cardiac defibrillator) or
ICD-9 code V45.01 (cardiac pacemaker),
• 	ICD-10-CM is applicable, ICD-10 code Z95.810 (automatic implantable cardiac defibrillator)or
ICD-10 code Z95.0 (cardiac pacemaker),
• 	Modifier Q0,
• 	If ICD-9-CM is applicable, ICD-9 code V70.7 Examination of participant in clinical trial (for
institutional claims only)or
• 	If ICD-10-CM is applicable, ICD-10 code Z00.6 – Examination of participant in clinical trial (for
institutional claims only), and
• 	Condition code 30 (for institutional claims only).
The contractor shall use the following remittance advice messages and associated codes when
rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH
CORE Business Scenario Three.
Group Code: CO
CARC: 272
RARC: N386
MSN: 21.21
50 - Nuclear Medicine (CPT 78000 - 79999)
(Rev. 1, 10-01-03)
50.1 - Payments for Radionuclides
(Rev. 1, 10-01-03)
The TC RVUs for nuclear medicine procedures (CPT codes 78XXX for diagnostic nuclear medicine,
and codes 79XXX for therapeutic nuclear medicine) do not include the radionuclide used in connection
with the procedure. These substances are separately billed under codes A4641 and A4642 for diagnostic
procedures, and code 79900 for therapeutic procedures and are paid on a “By Report” basis depending
on the substance used. In addition, CPT code 79900 is separately payable in connection with certain
clinical brachytherapy procedures. (See §70.4 for brachytherapy procedures).
50.2 - Stressing Agent
(Rev. 1, 10-01-03)

A/B MACs (B) must make separate payment under code J1245 for pharmacologic stressing agents used
in connection with nuclear medicine and cardiovascular stress testing procedures furnished to
beneficiaries in settings in which TCs are payable. Such an agent is classified as a supply and covered
as an integral part of the diagnostic test. However, A/B MACs (B) pay for code J1245 under the policy
for determining payments for “incident to” drugs. See Chapter 17 for payment for drugs.
50.2.1 - A/B MAC (A) Payment for IV Persantine
(Rev. 1, 10-01-03)
The A/B MACs (A) pay drug IV Persantine based on the drug pricing methodology when used in
conjunction with nuclear medicine and cardiovascular stress testing procedures furnished to SNF
outpatients. Separate drug pricing methodology payments for IV Persantine is made in addition to
payments made for the procedure. SNFs bill HCPCS code J1245 (injection, dipyridamole, per 10 mg.)
with revenue code 0636.
50.2.2 - A/B MAC (A) Payment for Adenosine
(Rev. 1, 10-01-03)
SNF-533.3
The drug adenosine is paid based on the drug payment methodology when used as a pharmacologic
stressor for other diagnostic testing. Separate based payment for adenosine will be made in addition to
payments made for the procedure for SNF Part B patients. When billing for adenosine, HCPCS code
J0150 (Injection, adenosine, 6 mg.) should be reported with revenue code 0636.
50.3 - Application of Multiple Procedure Policy (CPT Modifier “-51”)
(Rev. 1, 10-01-03)
A/B MACs (B) must apply the multiple procedure reduction to the following nuclear medicine
diagnostic procedures: codes 78306, 78320, 78802, 78803, 78806, and 78807.
50.4 - Generation and Interpretation of Automated Data
(Rev. 1, 10-01-03)
Payment for CPT codes 78890 and 78891 is bundled into payments for the primary procedure.
60 - Positron Emission Tomography (PET) Scans – General Information
(Rev. 1833; Issued: 10-16-09; Effective Date: 04-03-09; Implementation Date: 10-30-09)
Positron emission tomography (PET) is a noninvasive imaging procedure that assesses perfusion and the
level of metabolic activity in various organ systems of the human body. A positron camera (tomograph)
is used to produce cross-sectional tomographic images which are obtained by detecting radioactivity
from a radioactive tracer substance (radiopharmaceutical) that emits a radioactive tracer substance
(radiopharmaceutical FDG) such as 2 –[F-18] flouro-D-glucose FDG, that is administered intravenously
to the patient.
The Medicare National Coverage Determinations (NCD) Manual, chapter 1, §220.6, contains additional
coverage instructions to indicate the conditions under which a PET scan is performed.
A. Definitions
For all uses of PET, excluding Rubidium 82 for perfusion of the heart, myocardial viability and
refractory seizures, the following definitions apply:
• 	Diagnosis: PET is covered only in clinical situations in which the PET results may assist in
avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the
optimal anatomical location to perform an invasive diagnostic procedure. In general, for most solid

tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a
tissue diagnosis are generally performed for the purpose of staging, rather than diagnosis. Therefore, the
use of PET in the diagnosis of lymphoma, esophageal and colorectal cancers, as well as in melanoma,
should be rare. PET is not covered for other diagnostic uses, and is not covered for screening (testing of
patients without specific signs and symptoms of disease).
• 	Staging: PET is covered in clinical situations in which (1) (a) the stage of the cancer remains in
doubt after completion of a standard diagnostic workup, including conventional imaging (computed
tomography, magnetic resonance imaging, or ultrasound) or, (b) the use of PET would also be
considered reasonable and necessary if it could potentially replace one or more conventional imaging
studies when it is expected that conventional study information is insufficient for the clinical
management of the patient and, (2) clinical management of the patient would differ depending on the
stage of the cancer identified.
NOTE: Effective for services on or after April 3, 2009, the terms “diagnosis” and “staging” will be
replaced with “Initial Treatment Strategy.” For further information on this new term, refer to Pub. 100-
03, NCD Manual, section 220.6.17.
• 	Restaging: PET will be covered for restaging: (1) after the completion of treatment for the
purpose of detecting residual disease, (2) for detecting suspected recurrence, or metastasis, (3) to
determine the extent of a known recurrence, or (4) if it could potentially replace one or more
conventional imaging studies when it is expected that conventional study information is to determine the
extent of a known recurrence, or if study information is insufficient for the clinical management of the
patient. Restaging applies to testing after a course of treatment is completed and is covered subject to
the conditions above.
• 	Monitoring: Use of PET to monitor tumor response to treatment during the planned course of
therapy (i.e., when a change in therapy is anticipated).
NOTE: Effective for services on or after April 3, 2009, the terms “restaging” and “monitoring” will be
replaced with “Subsequent Treatment Strategy.” For further information on this new term, refer to Pub.
100-03, NCD Manual, section 220.6.17.
B. Limitations
For staging and restaging: PET is covered in either/or both of the following circumstances:
• 	The stage of the cancer remains in doubt after completion of a standard diagnostic workup,
including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound);
and/or
• 	The clinical management of the patient would differ depending on the stage of the cancer
identified. PET will be covered for restaging after the completion of treatment for the purpose of
detecting residual disease, for detecting suspected recurrence, or to determine the extent of a known
recurrence. Use of PET would also be considered reasonable and necessary if it could potentially
replace one or more conventional imaging studies when it is expected that conventional study
information is insufficient for the clinical management of the patient.
The PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients
without specific symptoms). Use of PET to monitor tumor response during the planned course of
therapy (i.e., when no change in therapy is being contemplated) is not covered.
60.1 - Billing Instructions
(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11,
2013, ICD-10: Upon Implementation of ICD-10

Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission
Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7,
2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS,
MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)
A. Billing and Payment Instructions or Responsibilities for A/B MACs (B)
Claims for PET scan services must be billed using the ASC X12 837 professional claim format or on
Form-CMS 1500 with the appropriate HCPCS or CPT code and diagnosis codes to the A/B MAC (B).
Effective for claims received on or after July 1, 2001, PET modifiers were discontinued and are no
longer a claims processing requirement for PET scan claims. Therefore, July 1, 2001, and after the MSN
messages regarding the use of PET modifiers can be discontinued. The type of service (TOS) for the
new PET scan procedure codes is TOS 4, Diagnostic Radiology. Payment is based on the Medicare
Physician Fee Schedule.
B. Billing and Payment Instructions or Responsibilities for A/B MACs (A)
Claims for PET scan procedures must be billed to the A/B MAC (A) on the ASC X12 837 institutional
claim format or on Form CMS-1450 with the appropriate diagnosis and HCPCS “G” code or CPT code
to indicate the conditions under which a PET scan was done. These codes represent the technical
component costs associated with these procedures when furnished to hospital and SNF outpatients. They
are paid as follows:
• 	under OPPS for hospitals subject to OPPS
• 	under current payment methodologies for hospitals not subject to OPPS
• 	on a reasonable cost basis for critical access hospitals.
• 	on a reasonable cost basis for skilled nursing facilities.
Institutional providers bill these codes under Revenue Code 0404 (PET Scan).
Medicare contractors shall pay claims submitted for services provided by a critical access hospital
(CAH) as follows: Method I technical services are paid at 101% of reasonable cost; Method II technical
services are paid at 101% of reasonable cost, and professional services are paid at 115% of the Medicare
Physician Fee Schedule Data Base.
C. Frequency
In the absence of national frequency limitations, for all indications covered on and after July 1, 2001,
contractors can, if necessary, develop frequency limitations on any or all covered PET scan services.
D. Post-Payment Review for PET Scans
As with any claim, but particularly in view of the limitations on this coverage, Medicare may decide to
conduct post-payment reviews to determine that the use of PET scans is consistent with coverage
instructions. Pet scanning facilities must keep patient record information on file for each Medicare
patient for whom a PET scan claim is made. These medical records can be used in any post-payment
reviews and must include the information necessary to substantiate the need for the PET scan. These
records must include standard information (e.g., age, sex, and height) along with sufficient patient
histories to allow determination that the steps required in the coverage instructions were followed. Such
information must include, but is not limited to, the date, place and results of previous diagnostic tests
(e.g., cytopathology and surgical pathology reports, CT), as well as the results and reports of the PET
scan(s) performed at the center. If available, such records should include the prognosis derived from the
PET scan, together with information regarding the physician or institution to which the patient
proceeded following the scan for treatment or evaluation. The ordering physician is responsible for
forwarding appropriate clinical data to the PET scan facility.

Effective for claims received on or after July 1, 2001, CMS no longer requires paper documentation to
be submitted up front with PET scan claims. Contractors shall be aware and advise providers of the
specific documentation requirements for PET scans for dementia and neurodegenerative diseases. This
information is outlined in section 60.12. Documentation requirements such as physician referral and
medical necessity determination are to be maintained by the provider as part of the beneficiary’s medical
record. This information must be made available to the A/B MAC (A or B) upon request of additional
documentation to determine appropriate payment of an individual claim.
60.2 - Use of Gamma Cameras and Full Ring and Partial Ring PET Scanners for
PET Scans
(Rev. 527, Issued: 04-15-05, Effective: 01-28-05, Implementation: 04-18-05)
See the Medicare NCD Manual, Section 220.6, concerning 2-[F-18] Fluoro-D-Glucose (FDG) PET
scanners and details about coverage.
On July 1, 2001, HCPCS codes G0210 - G0230 were added to allow billing for all currently covered
indications for FDG PET. Although the codes do not indicate the type of PET scanner, these codes were
used until January 1, 2002, by providers to bill for services in a manner consistent with the coverage
policy.
Effective January 1, 2002, HCPCS codes G0210 – G0230 were updated with new descriptors to properly
reflect the type of PET scanner used. In addition, four new HCPCS codes became effective for dates of
service on and after January 1, 2002, (G0231, G0232, G0233, G0234) for covered conditions that may
be billed if a gamma camera is used for the PET scan. For services performed from January 1, 2002,
through January 27, 2005, providers should bill using the revised HCPCS codes G0210 - G0234.
Beginning January 28, 2005 providers should bill using the appropriate CPT code.
60.2.1 - Coverage for Myocardial Viability
(Rev. 1, 10-01-03)
AB-02-065
The FDG PET is covered for the determination of myocardial viability following an inconclusive single
photon computed tomography test (SPECT) from July 1, 2001, through September 30, 2002. Only full
ring scanners are covered as the scanning medium for this service from July 1, 2001, through December
31, 2001. However, as of January 1, 2002, full and partial ring scanners are covered for myocardial
viability following an inconclusive SPECT.
Beginning October 1, 2002, Medicare will cover FDG PET for the determination of myocardial viability
as a primary or initial diagnostic study prior to revascularization, and will continue to cover FDG PET
when used as a follow-up to an inconclusive SPECT. However, if a patient received a FDG PET study
with inconclusive results, a follow-up SPECT is not covered. FDA full and partial ring PET scanners
are covered.
In the event that a patient receives a SPECT with inconclusive results, a PET scan may be performed and
covered by Medicare. However, a SPECT is not covered following a FDG PET with inconclusive
results. See the Medicare National Coverage Determinations Manual for specific frequency limitations
for Myocardial Viability following an inconclusive SPECT.
In the absence of national frequency limitations, contractors can, if necessary develop reasonable
frequency limitations for myocardial viability.
Documentation that these conditions are met should be maintained by the referring physician as part of
the beneficiary’s medical record.
60.3 - PET Scan Qualifying Conditions and HCPCS Code Chart
(Rev. 527, Issued: 04-15-05, Effective: 01-28-05, Implementation: 04-18-05)

Below is a summary of all covered PET scan conditions, with effective dates.
NOTE: The G codes below except those a # can be used to bill for PET Scan services through January
27, 2005. Effective for dates of service on or after January 28, 2005, providers must bill for PET Scan
services using the appropriate CPT codes. See section 60.3.1. The G codes with a # can continue to be
used for billing after January 28, 2005 and these remain non-covered by Medicare. (NOTE: PET
Scanners must be FDA-approved.)

Conditions 	Coverage
Effective
Date
****HCPCS/CPT
*Myocardial perfusion imaging (following previous
PET G0030-G0047) single study, rest or stress
(exercise and/or pharmacologic)
3/14/95 	G0030
*Myocardial perfusion imaging (following previous
PET G0030-G0047) multiple studies, rest or stress
(exercise and/or pharmacologic)
3/14/95 	G0031
*Myocardial perfusion imaging (following rest
SPECT, 78464); single study, rest or stress (exercise
and/or pharmacologic)
3/14/95 	G0032
*Myocardial perfusion imaging (following rest
SPECT 78464); multiple studies, rest or stress
(exercise and/or pharmacologic)
3/14/95 	G0033
*Myocardial perfusion (following stress SPECT
78465); single study, rest or stress (exercise and/or
pharmacologic)
3/14/95 	G0034
*Myocardial Perfusion Imaging (following stress
SPECT 78465); multiple studies, rest or stress
(exercise and/or pharmacologic)
3/14/95 	G0035
*Myocardial Perfusion Imaging (following coronary
angiography 93510-93529); single study, rest or
stress (exercise and/or pharmacologic)
3/14/95 	G0036
*Myocardial Perfusion Imaging, (following
coronary angiography), 93510-93529); multiple
studies, rest or stress (exercise and/or
pharmacologic)
3/14/95 	G0037
*Myocardial Perfusion Imaging (following stress
planar myocardial perfusion, 78460); single study,
rest or stress (exercise and/or pharmacologic)
3/14/95 	G0038
Conditions 	Coverage
Effective
Date
****HCPCS/CPT
*Myocardial Perfusion Imaging (following stress
planar myocardial perfusion, 78460); multiple
studies, rest or stress (exercise and/or
pharmacologic)
3/14/95 	G0039
*Myocardial Perfusion Imaging (following stress
echocardiogram 93350); single study, rest or stress
(exercise and/or pharmacologic)
3/14/95 	G0040
*Myocardial Perfusion Imaging (following stress
echocardiogram, 93350); multiple studies, rest or
stress (exercise and/or pharmacologic)
3/14/95 	G0041

*Myocardial Perfusion Imaging (following stress
nuclear ventriculogram 78481 or 78483); single
study, rest or stress (exercise and/or pharmacologic)
3/14/95 	G0042
*Myocardial Perfusion Imaging (following stress
nuclear ventriculogram 78481 or 78483); multiple
studies, rest or stress (exercise and/or
pharmacologic)
3/14/95 	G0043
*Myocardial Perfusion Imaging (following stress
ECG, 93000); single study, rest or stress (exercise
and/or pharmacologic)
3/14/95 	G0044
*Myocardial perfusion (following stress ECG,
93000), multiple studies; rest or stress (exercise
and/or pharmacologic)
3/14/95 	G0045
*Myocardial perfusion (following stress ECG,
93015), single study; rest or stress (exercise and/or
pharmacologic)
3/14/95 	G0046
*Myocardial perfusion (following stress ECG,
93015); multiple studies, rest or stress (exercise
and/or pharmacologic)
3/14/95 	G0047
PET imaging regional or whole body; single
pulmonary nodule
1/1/98 	G0125
Conditions 	Coverage
Effective
Date
****HCPCS/CPT
Lung cancer, non-small cell (PET imaging whole
body)
Diagnosis, Initial Staging, Restaging
7/1/01 	G0210
G0211
G0212
Colorectal cancer (PET imaging whole body)
Diagnosis, Initial Staging, Restaging
7/1/01 	G0213
G0214
G0215
Melanoma (PET imaging whole body)
Diagnosis, Initial Staging, Restaging
7/1/01 	G0216
G0217
G0218
Melanoma for non-covered indications 	7/1/01 	#G0219
Lymphoma (PET imaging whole body)
Diagnosis, Initial Staging, Restaging
7/1/01 	G0220
G0221
G0222

Head and neck cancer; excluding thyroid and CNS
cancers (PET imaging whole body or regional)
Diagnosis, Initial Staging, Restaging
7/1/01 	G0223
G0224
G0225
Esophageal cancer (PET imaging whole body)
Diagnosis, Initial Staging, Restaging
7/1/01 	G0226
G0227
G0228
Metabolic brain imaging for pre-surgical evaluation
of refractory seizures
7/1/01 	G0229
Metabolic assessment for myocardial viability
following inconclusive SPECT study
7/1/01 	G0230
Recurrence of colorectal or colorectal metastatic
cancer (PET whole body, gamma cameras only)
1/1/02 	G0231
Staging and characterization of lymphoma (PET
whole body, gamma cameras only)
1/1/02 	G0232
Conditions 	Coverage
Effective
Date
****HCPCS/CPT
Recurrence of melanoma or melanoma metastatic
cancer (PET whole body, gamma cameras only)
1/1/02 	G0233
Regional or whole body, for solitary pulmonary
nodule following CT, or for initial staging of non-
small cell lung cancer (gamma cameras only)
1/1/02 	G0234
Non-Covered Service
PET imaging, any site not otherwise specified
1/28/05 	#G0235
Non-Covered Service
Initial diagnosis of breast cancer and/or surgical
planning for breast cancer (e.g., initial staging of
axillary lymph nodes), not covered (full- and partial-
ring PET scanners only)
10/1/02 	#G0252
Breast cancer, staging/restaging of local regional
recurrence or distant metastases, i.e.,
staging/restaging after or prior to course of treatment
(full- and partial-ring PET scanners only)
10/1/02 	G0253
Breast cancer, evaluation of responses to treatment,
performed during course of treatment (full- and
partial-ring PET scanners only)
10/1/02 	G0254
Myocardial imaging, positron emission tomography
(PET), metabolic evaluation)
10/1/02 	78459
Restaging or previously treated thyroid cancer of
follicular cell origin following negative I-131 whole
body scan (full- and partial-ring PET scanner only)
10/1/03 	G0296

Tracer Rubidium**82 (Supply of
Radiopharmaceutical Diagnostic Imaging Agent)
(This is only billed through Outpatient Perspective
Payment System, OPPS.) (A/B MACs (B) must use
HCPCS Code A4641).
10/1/03 	Q3000
***Supply of Radiopharmaceutical Diagnostic
Imaging Agent, Ammonia N-13***
01/1/04 	A9526
Conditions 	Coverage
Effective
Date
****HCPCS/CPT
PET imaging, brain imaging for the differential
diagnosis of Alzheimer’s disease with aberrant
features vs. fronto-temporal dementia
09/15/04 	Appropriate CPT Code from
section 60.3.1
PET Cervical Cancer
Staging as adjunct to conventional imaging, other
staging, diagnosis, restaging, monitoring
1/28/05 	Appropriate CPT Code from
section 60.3.1
*NOTE: A/B MACs (B) must report A4641 for the tracer Rubidium 82 when used with PET scan
codes G0030 through G0047 for services performed on or before January 27, 2005
**NOTE: Not FDG PET
***NOTE: For dates of service October 1, 2003, through December 31, 2003, use temporary code
Q4078 for billing this radiopharmaceutical.
60.3.1 - Appropriate CPT Codes Effective for PET Scans for Services Performed on
or After January 28, 2005
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)
NOTE: All PET scan services require the use of a radiopharmaceutical diagnostic
imaging agent (tracer). The applicable tracer code should be billed when billing for a
PET scan service. See section 60.3.2 below for applicable tracer codes.
CPT Code 	Description
78429 	Myocardial imaging, positron emission tomography (PET), metabolic evaluation
study, single study; with concurrently acquired computed tomography transmission
scan
78430 	Myocardial imaging, positron emission tomography (PET), perfusion study;
single study, at rest or stress (exercise or pharmacologic), with concurrently
acquired computed tomography transmission scan
78431 	Myocardial imaging, positron emission tomography (PET), perfusion study;
multiple studies at rest and stress, with concurrently acquired computed
tomography transmission scan
78432 	Myocardial imaging, positron emission tomography (PET), combined
perfusion with metabolic evaluation study, dual radiotracer;
78433 	Myocardial imaging, positron emission tomography (PET), combined
perfusion with metabolic evaluation study, dual radiotracer; with concurrently
acquired computed tomography transmission scan

78434 	Absolute quantitation of myocardial blood flow (AQMBF), positron emission
tomography (PET), rest and pharmacologic stress
78459 	Myocardial imaging, positron emission tomography (PET), metabolic evaluation
78491 	Myocardial imaging, positron emission tomography (PET), perfusion, single study
at rest or stress
78492 	Myocardial imaging, positron emission tomography (PET), perfusion, multiple
studies at rest and/or stress
78608 	Brain imaging, positron emission tomography (PET); metabolic evaluation
78811 	Tumor imaging, positron emission tomography (PET); limited area (eg, chest,
head/neck)
78812 	Tumor imaging, positron emission tomography (PET); skull base to mid-thigh
78813 	Tumor imaging, positron emission tomography (PET); whole body
60.3.2 - Tracer Codes Required for Positron Emission Tomography (PET) Scans
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)
An applicable tracer/radiopharmaceutical code, along with an applicable Current
Procedural Technology (CPT) code, is necessary for claims processing of any Positron
Emission Tomography (PET) scan services. While there are a number of PET tracers
already billable for a diverse number of medical indications, there have been, and may be
in the future, additional PET indications that might require a new PET tracer. Under
those circumstances, the process to request/approve/implement a new code could be
time- intensive. To help alleviate inordinate spans of time between when a national
coverage determination is made, or when the Food and Drug Administration (FDA)
approves a particular radiopharmaceutical for an oncologic indication already approved
by the Centers for Medicare & Medicaid Services (CMS), and when it can be fully
implemented via valid claims processing, CMS has created two new PET
radiopharmaceutical unclassified tracer codes that can be used temporarily. This time
period would be pending the creation/approval/implementation of permanent CPT codes
that would later specifically define their function by CMS in official instructions.
Effective with dates of service on or after January 1, 2018, the following Healthcare
Common Procedure Coding System (HCPCS) codes shall be used ONLY AS
NECESSARY FOR AN INTERIM PERIOD OF TIME under the circumstances
explained here. Specifically, there are two circumstances that would warrant use of the
CPT Code 	Description
78814 	Tumor imaging, positron emission tomography (PET) with concurrently acquired
computed tomography (CT) for attenuation correction and anatomical localization;
limited area (e.g., chest, head/neck)
78815 	Tumor imaging, positron emission tomography (PET) with concurrently acquired
computed tomography (CT) for attenuation correction and anatomical localization;
skull base to mid-thigh
78816 	Tumor imaging, positron emission tomography (PET) with concurrently acquired
computed tomography (CT) for attenuation correction and anatomical localization;
whole body

below codes: (1) After FDA approval of a PET oncologic indication, or, (2) after CMS
approves coverage of a new PET indication, and ONLY if either of those situations
requires the use of a dedicated PET radiopharmaceutical/tracer that is currently non-
existent. Once permanent replacement codes are officially implemented by CMS, use of
the temporary code for that particular indication will simultaneously be discontinued.
NOTE: The following two codes were effective as of January 1, 2017, with the January
2017 quarterly HCPCS update.
A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor
identification, not otherwise classified
A9598 - Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor
identification, not otherwise classified
Effective for claims with dates of service on and after January 1, 2018, when PET
tracer code A9597 or A9598 are present on a claim, that claim must also include:
-an appropriate PET HCPCS code, either 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491,
78492, 78608, 78811, 78812, 78813, 78814, 78815, or 78816,
-if tumor-related, either the -PI or -PS modifier as appropriate,
-if clinical trial, registry, or study-related outside of NCD220.6.17, PET for Solid
Tumors, clinical trial modifier –Q0,
-if clinical trial, registry, or study-related, all claims require the 8-digit clinical trial
number,
-if Part A OP and clinical trial, registry, or study-related outside of NCD220.6.17, PET
for Solid Tumors, also include condition code 30 and ICD-10 diagnosis Z00.6.
Effective for claims with dates of service on and after January 1, 2018, A/Medicare
Administrative Contractors (MACs) shall line-item deny, and B/MACs shall line-item
reject, PET claims for A9597 or A9598 that don't include the elements noted above as
appropriate.
Contractors shall use the following messaging when line-item denying (Part A) or line-
item rejecting (Part B) PET claims containing HCPCS A9597 or A9598:
Remittance Advice Remark Codes (RARC) N386
Claim Adjustment Reason Code (CARC) 50, 96, and/or 119.
Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a
claim is received with a GZ modifier indicating no signed ABN is on file).
(The above new verbiage will supersede any existing verbiage in chapter 13,
section 60.3.2.)
60.3.3 - Denial Messages for Noncovered PET Services
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17)
The A/B MAC denies claims for noncovered procedure code, such as 78609.
The contractor shall use the following remittance advice messages and associated codes when
rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH
CORE Business Scenario Three.
Group Code: CO
CARC: 96
RARC: N386
MSN: 16.10
60.4 - PET Scans for Imaging of the Perfusion of the Heart Using Rubidium 82 (Rb
82)
(Rev. 223, Issued: 07-02-04) (Effective/Implementation: Not Applicable)

For dates of service on or after March 14, 1995, Medicare covers one PET scan for imaging of the
perfusion of the heart using Rubidium 82 (Rb 82), provided that the following conditions are met:
• 	The PET is done at a PET imaging center with a PET scanner that has been approved by the
FDA;
• 	The PET scan is a rest alone or rest with pharmacologic stress PET scan, used for noninvasive
imaging of the perfusion of the heart for the diagnosis and management of patients with known
or suspected coronary artery disease, using Rb 82; and
• 	Either the PET scan is used in place of, but not in addition to, a single photon emission computed
tomography (SPECT) or the PET scan is used following a SPECT that was found inconclusive.
60.5 - Expanded Coverage of PET Scan for Solitary Pulmonary Nodules (SPNs)
(Rev. 223, Issued: 07-02-04) (Effective/Implementation: Not Applicable)
For dates of service on or after January 1, 1998, Medicare expanded PET scan coverage to include
characterization of solitary pulmonary nodules (SPNs).
60.6 - Expanded Coverage of PET Scans Effective for Services on or after July 1,
1999
(Rev. 223, Issued: 07-02-04) (Effective/Implementation: Not Applicable)
Effective for services performed on or after July 1, 1999, Medicare expanded coverage of PET scans to
include the evaluation of recurrent colorectal cancer in patients with rising levels of carinoembryonic
antigen (CEA), for the staging of lymphoma (both Hodgkins and non-Hodgkins) when the PET scan
substitutes for a gallium scan or lymphangiogram, and for the staging of recurrent melanoma prior to
surgery, provided certain conditions are met. All three indications are covered only when using the
radiopharmaceutical FDG- (2-[flourine-18]-fluoro-2-deoxy-D-glucose), and are further predicated on the
legal availability of FDG for use in such scans.
60.7 - Expanded Coverage of PET Scans Effective for Services on or After July 1,
2001
(Rev. 223, Issued: 07-02-04) (Effective/Implementation: Not Applicable)
See the Medicare National Coverage Determinations Manual, section 220.6, for specific coverage
criteria for PET Scans. Coverage is expanded for PET scans to include the following effective July 1,
2001:
• 	Scans performed with dedicated full-ring scanners will be covered. Gamma camera systems with
at least a 1 inch thick crystal are eligible for coverage in addition to those already approved by CMS
(FDA approved);
• 	The provider must maintain on file the doctor’s referral and documentation that the procedure
involved:
o 	Only FDA approved drugs and devices and,
o 	Did not involve investigational drugs, or procedures using investigational drugs, as
determined by the FDA;
• 	The ordering physician is responsible for certifying the medical necessity of the study according
to the conditions. The physician must have documentation in the beneficiary’s medical record to support
the referral supplied to the PET scan provider.
The following is a brief summary of the expanded coverage as of July 1, 2001:

• 	PET is covered for diagnosis, initial staging and restaging of non-small cell lung cancer
(NSCLC).
• 	Usage of PET for colorectal cancer has been expanded to include diagnosis, staging, and
restaging.
• 	Usage of PET for the initial staging, and restaging of both Hodgkin’s and non-Hodgkin’s disease.
• 	Usage of PET for the diagnosis, initial staging, and restaging of melanoma. (PET Scans are
NOT covered for the evaluation of regional nodes.)
• 	Medicare covers PET for the diagnosis, initial staging, and restaging of esophageal cancer.
• 	Usage of PET for Head and Neck Cancers. (PET scans for head and neck cancer is NOT
covered for central nervous system or thyroid cancers.)
• 	Usage of PET following an inconclusive single photon emission computed tomography (SPECT)
only for myocardial viability. In the event that a patient has received a SPECT and the physician finds
the results to be inconclusive, only then may a PET scan be ordered utilizing the proper documentation.
• 	Usage of PET for pre-surgical evaluation for patients with refractory seizures.
NOTE: Effective January 1, 2002, the definitions of HCPCS Codes G0210 through G0230 have been
updated to properly reflect the type of PET scanner used.
60.8 - Expanded Coverage of PET Scans for Breast Cancer Effective for Dates of
Service on or After October 1, 2002
(Rev. 527, Issued: 04-15-05, Effective: 01-28-05, Implementation: 04-18-05)
Effective for dates of service on or after October 1, 2002, Medicare will cover FDG PET as an adjunct to
other imaging modalities for staging and restaging for locoregional, recurrence or metastasis of breast
cancer. Monitoring treatment of a locally advanced breast cancer tumor and metastatic breast cancer
when a change in therapy is contemplated is also covered as an adjunct to other imaging modalities. The
baseline PET study for monitoring should be done under the code for staging or restaging.
Medicare continues to have a national non-coverage determination for initial diagnosis of breast cancer
and initial staging of axillary lymph nodes. Medicare coverage now includes PET as an adjunct to
standard imaging modalities for staging patients with distant metastasis or restaging patients with
locoregional recurrence or metastasis of breast cancer; as an adjunct to standard imaging modalities for
monitoring for women with locally advanced and metastatic breast cancer when a change in therapy is
contemplated.
CPT Codes for PET Scans Performed on or After October 1, 2002 for Breast Cancer
Contractors shall advise providers to use the appropriate CPT code from section 60.3.1 for covered
breast cancer indications for services performed on or after January 28, 2005.
NOTE: 	The NCD Manual contains a description of coverage. FDG Positron Emission Tomography
is a minimally invasive diagnostic procedure using positron camera [tomograph] to measure
the decay of radioisotopes such as FDG. The CMS determined that the benefit category for
the requested indications fell under §1861(s)(3) of the Act diagnostic service.
60.9 - Coverage of PET Scans for Myocardial Viability
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)

FDG PET is covered for the determination of myocardial viability following an
inconclusive single photon computed tomography test (SPECT) from July 1, 2001,
through September 30, 2002. Only full ring scanners are covered as the scanning
medium for this service from July 1, 2001, through December 31, 2001. However, as of
January 1, 2002, full and partial ring scanners are covered for myocardial viability
following an inconclusive SPECT.
Beginning October 1, 2002, Medicare will cover FDG PET for the
determination of myocardial viability as a primary or initial diagnostic
study prior to revascularization, and will continue to cover FDG PET
when used as a follow-up to an inconclusive SPECT. However, if a patient
received a FDG PET study with inconclusive results, a follow-up SPECT
is not covered. FDA full and partial ring PET scanners are covered. In the
event that a patient receives a SPECT with inconclusive results, a PET
scan may be performed and covered by Medicare. However, a SPECT is
not covered following a FDG PET with inconclusive results. See the
Medicare National Coverage Determinations Manual, Section 220.6 for
specific frequency limitations for Myocardial Viability following an
inconclusive SPECT.
Documentation that these conditions are met should be maintained
by the referring provider as part of the beneficiary’s medical
record.
HCPCS Code for PET Scan for Myocardial Viability
78429-Myocardial imaging, positron emission tomography (PET), metabolic evaluation
study, single study; with concurrently acquired computed tomography transmission scan
78432-Myocardial imaging, positron emission tomography (PET), combined perfusion
with metabolic evaluation study, dual radiotracer;
78433-Myocardial imaging, positron emission tomography (PET), combined perfusion
with metabolic evaluation study, dual radiotracer; with concurrently acquired computed
tomography transmission scan
78459 - Myocardial imaging, positron emission tomography (PET), metabolic
evaluation
60.10 - Coverage of PET Scans for PET Scan for Thyroid Cancer
(Rev. 527, Issued: 04-15-05, Effective: 01-28-05, Implementation: 04-18-05)
For services furnished on or after October 1, 2003, Medicare covers the use of FDG PET
for thyroid cancer only for restaging of recurrent or residual thyroid cancers of folliculark
cell origin that have previously been treated by thyroidectomy and radioiodine ablation
and have a serum thyroglobulin > 10ng/ml and negative I-131 whole body scan.
Contractors shall advise providers to use the appropriate CPT code from section 60.3.1
for thyroid cancer for services performed on or after January 28, 2005.
60.11 - Coverage of PET Scans for Perfusion of the Heart Using
Ammonia N-13
(Rev. 223, Issued: 07-02-04) (Effective/Implementation: Not Applicable)

Effective for service performed on or after October 1, 2003, PET scans performed at rest
or with pharmacological stress used for noninvasive imaging of the perfusion of the heart
for the diagnosis and management of patients with known or suspected coronary artery
disease using the FDA-approved radiopharmaceutical ammonia N-13 are covered,
provided the following requirements are met.
60.12 - Coverage for PET Scans for Dementia and Neurodegenerative
Diseases
(Rev. 12364; Issued: 11-16-23; Effective: 10-13-23; Implementation:12-19-23)
Effective for dates of service on or after September 15, 2004, Medicare will cover
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scans for a differential
diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease (AD) 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,
National Coverage Determination (NCD) Manual, section 220.6.13, for complete
coverage conditions.
A. NCD 220.6.13 - A/B Medicare Administrative Contractors (MACs) (A and B) Billing
Requirements for PET Scan Claims for FDG-PET for the Differential Diagnosis of
Fronto-temporal Dementia and Alzheimer’s Disease:
Current Procedural Terminology (CPT) Code for PET Scans for Dementia and
Neurodegenerative Diseases
Contractors shall advise providers to use the appropriate CPT 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:
• 	ICD-10-CM is applicable, ICD-10 codes are: F03.90, F03.90 plus F05, G30.9,
G31.01, G31.9, R41.2 or R41.3
Medicare contractors shall deny claims when submitted with an appropriate CPT code
from section 60.3.1 and with a diagnosis code other than the range of codes listed above.
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.
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This Claim Adjustment Reason Code

(CARC)/Remittance Advice Remark Code (RARC) combination is compliant with
CAQH CORE Business Scenario Three.
-Group Code: PR (patient responsibility) (if claim is received with a GA modifier)
otherwise CO (contractual obligation)
-CARC: 11
-RARC: N/A
-Medicare Summary Notice (MSN): 16.48
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.
B. NCD 220.6.20 - Billing Requirements for Beta Amyloid Positron Emission
Tomography (PET) in Dementia and Neurodegenerative Disease.
Effective October 13, 2023, as a result of the reconsideration of NCD 220.6.20, and
under section 1862(a)(1)(A) of the Social Security Act, this NCD has been removed.
Coverage determinations are now made by the MACs. See NCD 220.6.20 of the NCD
Manual.
Effective for claims with dates of service on and after September 27, 2013, thru
October 12, 2023, Medicare will only allow coverage with evidence development
(CED) for PET beta amyloid (also referred to as amyloid-beta (Aβ)) imaging
(Healthcare Common Procedure Coding System (HCPCS) A9586) or (HCPCS Q9982)
or (HCPCS Q9983) (one PET Aβ scan per patient).
Effective for dates of service on or after September 27, 2013, thru October 12,
2023, contractors shall return as unprocessable/return to provider claims for PET
Aβ imaging, through CED during a clinical trial, not containing the following:
• 	Condition code 30, and value code D4 (FI only)
• 	Modifier Q0 as appropriate
• 	ICD-10 dx code Z00.6 (in either the primary/secondary position)

• 	A PET HCPCS code (78811 or 78814)
• 	At least one diagnosis code from the table below,
And one of these additional diagnoses is required in addition to Z00.6
F03.90 	Unspecified dementia without behavioral disturbance
F03.91 	Unspecified dementia with behavioral disturbance
F01.50 	Vascular dementia without behavioral disturbance
F01.51 	Vascular dementia with behavioral disturbance
F02.80 	Dementia in other diseases classified elsewhere without behavioral
disturbance
F02.81 	Dementia in other diseases classified elsewhere with behavioral
disturbance
G31.01 	Pick's disease
G31.09 	Other frontotemporal dementia
G31.85 	Corticobasal degeneration
G31.83 	Dementia with Lewy bodies
G31.84 	Mild cognitive impairment, so stated
R41.1 	Anterograde amnesia
R41.2 	Retrograde amnesia
R41.3 	Other amnesia (amnesia NOS, memory loss NOS)
and
• 	Aβ HCPCS code A9586 or Q9982 or Q9983.
MSN, RARC and CARC Codes
Contractors shall return as unprocessable claims for PET Aβ imaging using the following
messages:
-CARC 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.
-RARC N519 - Invalid combination of HCPCS modifiers.
Contractors shall line-item deny claims for PET Aβ, HCPCS code A9586 or
Q9982 or Q9983, where a previous PET Aβ, HCPCS code A9586 or Q9982 or
Q9983 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
60.13 - Billing Requirements for PET Scans for Specific Indications of
Cervical Cancer for Services Performed on or After January 28, 2005
(Rev. 1888; Issued: 01-06-10, Effective date: 11-10-09; Implementation Date: 01-
04-10)
Contractors shall accept claims for these services with the appropriate CPT code listed in
section 60.3.1. Refer to Pub. 100-03, section 220.6.17, for complete coverage guidelines
for this new PET oncology indication. The implementation date for these CPT codes will
be April 18, 2005. Also see section 60.17, of this chapter for further claims processing
instructions for cervical cancer indications.
60.14 - Billing Requirements for PET Scans for Non-Covered
Indications
(Rev. 527, Issued: 04-15-05, Effective: 01-28-05, Implementation: 04-18-05)
For services performed on or after January 28, 2005, contractors shall accept claims with
the following HCPCS code for non-covered PET indications:
- G0235: PET imaging, any site not otherwise specified
Short Descriptor: PET not otherwise specified
Type of Service: 4
NOTE: This code is for a non-covered service.
60.15 - Billing Requirements for CMS - Approved Clinical Trials and
Coverage With Evidence Development Claims for PET Scans for
Neurodegenerative Diseases, Previously Specified Cancer Indications,
and All Other Cancer Indications Not Previously Specified
(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012

Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid
Tumors: June 11, 2013, ICD-10: Upon Implementation of ICD-10
Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron
Emission Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared
System Edits; July 7, 2014 - CWF development/testing, FISS requirement
development; October 6, 2014 - CWF, FISS, MCS Shared System Edits), ICD-10:
Upon Implementation of ICD-10)
A/B MACs (A and B)
Effective for services on or after January 28, 2005, contractors shall accept and pay for
claims for Positron Emission Tomography (PET) scans for lung cancer, esophageal
cancer, colorectal cancer, lymphoma, melanoma, head & neck cancer, breast cancer,
thyroid cancer, soft tissue sarcoma, brain cancer, ovarian cancer, pancreatic cancer, small
cell lung cancer, and testicular cancer, as well as for neurodegenerative diseases and all
other cancer indications not previously mentioned in this chapter, if these scans were
performed as part of a Centers for Medicare & Medicaid (CMS)-approved clinical trial.
(See Pub. 100-03, National Coverage Determinations (NCD) Manual, sections 220.6.13
and 220.6.17.)
Contractors shall also be aware that PET scans for all cancers not previously specified at
Pub. 100-03, NCD Manual, section 220.6.17, remain nationally non-covered unless
performed in conjunction with a CMS-approved clinical trial.
Effective for dates of service on or after June 11, 2013, Medicare has ended the coverage
with evidence development (CED) requirement for FDG (2-[F18] fluoro-2-deoxy-D-
glucose) PET and PET/computed tomography (CT) and PET/magnetic resonance
imaging (MRI) for all oncologic indications contained in section 220.6.17 of the NCD
Manual. Modifier -Q0 (Investigational clinical service provided in a clinical research
study that is in an approved clinical research study) or -Q1 (routine clinical service
provided in a clinical research study that is in an approved clinical research study) is no
longer mandatory for these services when performed on or after June 11, 2013.
A/B MACs (B) Only
A/B MACs (B) shall pay claims for PET scans for beneficiaries participating in a CMS-
approved clinical trial submitted with an appropriate current procedural terminology
(CPT) code from section 60.3.1 of this chapter and modifier Q0/Q1 for services
performed on or after January 1, 2008, through June 10, 2013. (NOTE: Modifier QR
(Item or service provided in a Medicare specified study) and QA (FDA investigational
device exemption) were replaced by modifier Q0 effective January 1, 2008.) Modifier
QV (item or service provided as routine care in a Medicare qualifying clinical trial) was
replaced by modifier Q1 effective January 1, 2008.) Beginning with services performed
on or after June 11, 2013, modifier Q0/Q1 is no longer required for PET FDG services.
A/B MACs (A) Only

In order to pay claims for PET scans on behalf of beneficiaries participating in a CMS-
approved clinical trial, A/B MACs (A) require providers to submit claims with, if ICD-9-
CM is applicable, ICD-9 code V70.7; if ICD-10-CM is applicable, ICD-10 code Z00.6 in
the primary/secondary diagnosis position using the ASC X12 837 institutional claim
format or on Form CMS-1450, with the appropriate principal diagnosis code and an
appropriate CPT code from section 60.3.1. Effective for PET scan claims for dates of
service on or after January 28, 2005, through December 31, 2007, A/B MACs (A) shall
accept claims with the QR, QV, or QA modifier on other than inpatient claims. Effective
for services on or after January 1, 2008, through June 10, 2013, modifier Q0 replaced the-
QR and QA modifier, modifier Q1 replaced the QV modifier. Modifier Q0/Q1 is no
longer required for services performed on or after June 11, 2013.
60.16 - Billing and Coverage Changes for PET Scans Effective for
Services on or After April 3, 2009
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17)
A. Summary of Changes
Effective for services on or after April 3, 2009, Medicare will not cover the use of FDG
PET imaging to determine initial treatment strategy in patients with adenocarcinoma of
the prostate.
Medicare will also not cover FDG PET imaging for subsequent treatment strategy for
tumor types other than breast, cervical, colorectal, esophagus, head and neck (non-
CNS/thyroid), lymphoma, melanoma, myeloma, non-small cell lung, and ovarian, unless
the FDG PET is provided under the coverage with evidence development (CED)
paradigm (billed with modifier -Q0/-Q1, see section 60.15 of this chapter).
Medicare will cover FDG PET imaging for initial treatment strategy for myeloma.
Effective for services performed on or after June 11, 2013, Medicare has ended the CED
requirement for FDG PET and PET/CT and PET/MRI for all oncologic indications
contained in section 220.6.17 of the NCD Manual. Effective for services on or after June
11, 2013, the Q0/Q1 modifier is no longer required.
Beginning with services performed on or after June 11, 2013, contractors shall pay for up
to three (3) FDG PET scans when used to guide subsequent management of anti-tumor
treatment strategy (modifier PS) after completion of initial anti-cancer therapy (modifier
PI) for the exact same cancer diagnosis.
Coverage of any additional FDG PET scans (that is, beyond 3) used to guide subsequent
management of anti-tumor treatment strategy after completion of initial anti-tumor
therapy for the same cancer diagnosis will be determined by the A/B MACs (A or B).
Claims will include the KX modifier indicating the coverage criteria is met for coverage

of four or more FDG PET scans for subsequent treatment strategy for the same cancer
diagnosis under this NCD.
A different cancer diagnosis whether submitted with a PI or a PS modifier will begin the
count of one initial and three subsequent FDG PET scans not requiring the KX modifier
and four or more FDG PET scans for subsequent treatment strategy for the same cancer
diagnosis requiring the KX modifier.
NOTE: The presence or absence of an initial treatment strategy claim in a beneficiary’s
record does not impact the frequency criteria for subsequent treatment strategy claims for
the same cancer diagnosis.
NOTE: Providers please refer to the following link for a list of appropriate diagnosis
codes,
http://cms.gov/medicare/coverage/determinationprocess/downloads/petforsolidtumorsonc
ologicdxcodesattachment_NCD220_6_17.pdf
For further information regarding the changes in coverage, refer to Pub.100-03, NCD
Manual, section 220.6.17.
B. Modifiers for PET Scans
Effective for claims with dates of service on or after April 3, 2009, the following
modifiers have been created for use to inform for the initial treatment strategy of
biopsy-proven or strongly suspected tumors or subsequent treatment strategy of
cancerous tumors:
PI Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform
the initial treatment strategy of tumors that are biopsy proven or strongly suspected of
being cancerous based on other diagnostic testing.
Short descriptor: PET tumor init tx strat
PS Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform
the subsequent treatment strategy of cancerous tumors when the beneficiary's treatment
physician determines that the PET study is needed to inform subsequent anti-tumor
strategy.
Short descriptor: PS - PET tumor subsq tx strategy
C. Billing for A/B MACs (A and B)
Effective for claims with dates of service on or after April 3, 2009, contractors shall
accept FDG PET claims billed to inform initial treatment strategy with the following
CPT codes AND modifier PI: 78608, 78811, 78812, 78813, 78814, 78815, 78816.

Effective for claims with dates of service on or after April 3, 2009, contractors shall
accept FDG PET claims with modifier PS for the subsequent treatment strategy for
solid tumors using a CPT code above AND a cancer diagnosis code.
Contractors shall also accept FDG PET claims billed to inform initial treatment
strategy or subsequent treatment strategy when performed under CED with one of the
PET or PET/CT CPT codes above AND modifier PI OR modifier PS AND a cancer
diagnosis code AND modifier Q0/Q1. Effective for services performed on or after June
11, 2013, the CED requirement has ended and modifier Q0/Q1, along with condition
code 30 (institutional claims only), or ICD-9 code V70.7, (both institutional and
practitioner claims) are no longer required.
D. Medicare Summary Notices, Remittance Advice Remark Codes, and Claim
Adjustment Reason Codes
Effective for dates of service on or after April 3, 2009, contractors shall return as
unprocessable/return to provider claims that do not include the PI modifier with one of
the PET/PET/CT CPT codes listed in subsection C. above when billing for the initial
treatment strategy for solid tumors in accordance with Pub.100-03, NCD Manual,
section 220.6.17.
In addition, contractors shall return as unprocessable/return to provider claims that do
not include the PS modifier with one of the CPT codes listed in subsection C. above
when billing for the subsequent treatment strategy for solid tumors in accordance with
Pub.100-03, NCD Manual, section 220.6.17.
The contractor shall use the following remittance advice messages and associated codes
when returning claims under this policy. This CARC/RARC combination is compliant
with CAQH CORE Business Scenario Two.
Group Code: CO
CARC: 4
RARC: MA130
MSN: N/A
Effective for claims with dates of service on or after April 3, 2009, through June 10,
2013, contractors shall return as unprocessable/return to provider FDG PET claims
billed to inform initial treatment strategy or subsequent treatment strategy when
performed under CED without one of the PET/PET/CT CPT codes listed in subsection C.
above AND modifier PI OR modifier PS AND a cancer diagnosis code AND modifier
Q0/Q1.
The contractor shall use the following remittance advice messages and associated codes
when returning claims under this policy. This CARC/RARC combination is compliant
with CAQH CORE Business Scenario Two.

Group Code: CO
CARC: 4
RARC: MA130
MSN: N/A
Effective April 3, 2009, contractors shall deny claims with ICD-9/ICD-10 diagnosis code
185/C61 for FDG PET imaging for the initial treatment strategy of patients with
adenocarcinoma of the prostate.
For dates of service prior to June 11, 2013, contractors shall also deny claims for FDG
PET imaging for subsequent treatment strategy for tumor types other than breast,
cervical, colorectal, esophagus, head and neck (non-CNS/thyroid), lymphoma,
melanoma, myeloma, non-small cell lung, and ovarian, unless the FDG PET is provided
under CED (submitted with the Q0/Q1 modifier) and use the following messages:
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Three.
Group Code: PR (if claim is received with a GA modifier) otherwise CO
CARC: 50
RARC: N/A
MSN: 15.4
Effective for dates of service on or after June 11, 2013, contractors shall use the
following messages when denying claims in excess of three for PET FDG scans for
subsequent treatment strategy when the KX modifier is not included, identified by CPT
codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier PS, HCPCS
A9552, and the same cancer diagnosis code.
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Three.
Group Code: PR (if claim is received with a GA modifier) otherwise CO
CARC: 96
RARC: N435
MSN: 23.17
60.17 – Billing and Coverage Changes for PET Scans for Cervical
Cancer Effective for Services on or After November 10, 2009
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17)
A. Billing Changes for A/B MACs (A and B)

Effective for claims with dates of service on or after November 10, 2009, contractors
shall accept FDG PET oncologic claims billed to inform initial treatment strategy;
specifically for staging in beneficiaries who have biopsy-proven cervical cancer when the
beneficiary’s treating physician determines the FDG PET study is needed to determine
the location and/or extent of the tumor as specified in Pub. 100-03, section 220.6.17.
EXCEPTION: CMS continues to non-cover FDG PET for initial diagnosis of cervical
cancer related to initial treatment strategy.
NOTE: Effective for claims with dates of service on and after November 10, 2009, the –
Q0 modifier is no longer necessary for FDG PET for cervical cancer.
B. Medicare Summary Notices, Remittance Advice Remark Codes, and Claim
Adjustment Reason Codes
Additionally, contractors shall return as unprocessable /return to provider for FDG PET
for cervical cancer for initial treatment strategy billed without the following: one of the
PET/PET/ CT CPT codes listed in 60.16 C above AND modifier PI AND a cervical
cancer diagnosis code.
The contractor shall use the following remittance advice messages and associated codes
when returning claims under this policy. This CARC/RARC combination is compliant
with CAQH CORE Business Scenario Two.
Group Code: CO
CARC: 4
RARC: MA130
MSN: N/A
60.18 – Billing and Coverage Changes for PET (NaF-18) Scans to
Identify Bone Metastasis of Cancer Effective for Claims With Dates of
Services on or After February 26, 2010
(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07-
2021)
• 	Billing Changes for A/B MACs (A and B)
Effective for claims with dates of service on and after February 26, 2010, contractors
shall pay for NaF-18 PET oncologic claims to inform of initial treatment strategy (PI)
or subsequent treatment strategy (PS) for suspected or biopsy proven bone metastasis
ONLY in the context of a clinical study and as specified in Pub. 100-03, section
220.6. All other claims for NaF-18 PET oncology claims remain non-covered.
• 	Medicare Summary Notices, Remittance Advice Remark Codes, and
Claim Adjustment Reason Codes

Effective for claims with dates of service on or after February 26, 2010, contractors
shall return as unprocessable NaF-18 PET oncologic claims billed with modifier TC
or globally (for A/B MACs (A) modifier TC or globally does not apply) and
HCPCS A9580 to inform the initial treatment strategy or subsequent treatment
strategy for bone metastasis that do not include ALL of the following:
• 	PI or PS modifier AND
• 	PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816)
AND
• 	Cancer diagnosis code AND
• 	Q0 modifier - Investigational clinical service provided in a clinical
research study, are present on the claim.
NOTE: For institutional claims, continue to include ICD-10 diagnosis code
Z00.6 and condition code 30 to denote a clinical study.
The contractor shall use the following remittance advice messages and associated
codes when returning claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Two
Group Code:
CO CARC: 4
RARC: MA130
MSN: N/A
Effective for claims with dates of service on or after February 26, 2010, contractors
shall accept PET oncologic claims billed with modifier 26 and modifier KX to inform
the initial treatment strategy or subsequent treatment strategy for bone metastasis that
include
the following:
• 	PI or PS modifier AND
• 	PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816)
AND
• 	Cancer diagnosis code AND
• 	Q0 modifier - Investigational clinical service provided in a clinical
research study, are present on the claim.
NOTE: If modifier KX is present on the professional component service,
Contractors shall process the service as PET NaF-18 rather than PET with FDG.
Contractors shall also return as unprocessable NaF-18 PET oncologic professional
component claims (i.e., claims billed with modifiers 26 and KX) to inform the
initial treatment strategy or subsequent treatment strategy for bone metastasis
billed with HCPCS A9580.

The contractor shall use the following remittance advice messages and associated
codes when returning claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Two.
Group Code:
CO
CARC: 4
RARC: MA130
MSN: N/A
NOTE: Effective for claims with dates of service on or after 12/15/2017, HCPCS code
A9580 (NaF-18) is nationally non-covered.
60.19 – Local Coverage Determination for PET Using New, Proprietary
Radiopharmaceuticals for their FDA-Approved Labeled Indications for
Oncologic Imaging Only
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17)
Effective for dates of service on or after March 7, 2013, local Medicare Administrative
Contractors (MACs) may determine coverage within their respective jurisdictions for
positron emission tomography (PET) using radiopharmaceuticals for their Food and Drug
Administration (FDA) approved labeled indications for oncologic imaging. When the
local MAC determines that a claim is noncovered, the claim is denied:
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Three.
Group Code: PR (if claim is received with a GA modifier) otherwise CO
CARC: 167
RARC: N/A
MSN: 15.4
70 - Radiation Oncology (Therapeutic Radiology)
(Rev. 1, 10-01-03)
70.1 - Weekly Radiation Therapy Management (CPT 77419 - 77430)
(Rev. 1, 10-01-03)
A/B MACs (B) must pay for a physician’s weekly treatment management services under
code 77427. Billing entities must indicate on each claim the number of fractions for
which payment is sought.
A weekly unit of treatment management is equal to five fractions or treatment sessions.
A week for the purpose of making payments under these codes is comprised of five
fractions regardless of the actual time period in which the services are furnished. It is not

necessary that the radiation therapist personally examine the patient during each fraction
for the weekly treatment management code to be payable. Multiple fractions
representing two or more treatment sessions furnished on the same day may be counted
as long as there has been a distinct break in therapy sessions, and the fractions are of the
character usually furnished on different days. If, at the final billing of the treatment
course, there are three or four fractions beyond a multiple of five, those three or four
fractions are paid for as a week. If there are one or two fractions beyond a multiple of
five, payment for these services is considered as having been made through prior
payments.
EXAMPLE: 	18 fractions = 	4 weekly services
62 fractions = 12 weekly services
8 fractions = 	2 weekly services
6 fractions = 	1 weekly service
If billings have occurred which indicate that the treatment course has ended (and,
therefore, the number of residual fractions has been determined), but treatments resume,
adjust A/B MAC (B) payments for the additional services consistent with the above
policy.
EXAMPLE: 	8 fractions = payment for 2 weeks
2 additional fractions are furnished by the same physician. No additional
Medicare payment is made for the 2 additional fractions.
A. SNF Treatment Management Delivery Services
A SNF may not bill weekly treatment management services for its outpatients (codes
77419, 77420, 77425, 77430, and 77431). Instead, the SNF should bill for radiation
treatment delivery (codes 77401 - 77404, 77406 - 77409, 77411 - 77414, and 77416).
Also, SNFs bill for therapeutic radiology port film (code 77417), which was previously a
part of the weekly services. They enter the number of services in the units field.
70.2 - Services Bundled Into Treatment Management Codes
(Rev. 4267, Issued: 03-27-19, Effective: 01-01-19, Implementation: 03-25-19)
A/B MACs (B) do not make separate payment for services rendered by the radiation
oncologists or in conjunction with radiation therapy.
11920 Tattooing, intradermal introduction of insoluble opaque pigments to
correct color defects of skin; 6.0 sq. cm or less
11921 6.11 to 20.0 sq. cm
11922 Each additional 20.0 sq. cm

16000 Initial treatment, first-degree burn, when no more than local treatment is
required
16010 Dressings and/or debridement, initial or subsequent; under anesthesia,
small
16015 Under anesthesia, medium or large, or with major debridement
16020 Without anesthesia, office or hospital, small
16025 Without anesthesia, medium (e.g., whole face or whole extremity)
16030 Without anesthesia, large (e.g., more than one extremity)
36425 Venipuncture, cut down age 1 or over
53670 Catheterization, urethra; simple
53675 Complicated (may include difficult removal of balloon catheter)
99211 Office or other outpatient visit, established patient; Level I*
99212 Level II*
99213 Level III*
99214 Level IV
99215 Level V
99238 Hospital discharge day management
99281 Emergency department visit, new or established patient; Level I
99282 Level II
99283 Level III
99284 Level IV
99285 Level V
90780 IV Infusion therapy, administered by physician or under direct supervision
of physician; up to one hour
90781 Each additional hour, up to 8 hours
90847 Family medical psychotherapy (conjoint psychotherapy) by a physician,
with continuing medical diagnostic evaluation, and drug management
when indicated
99050 Services requested after office hours in addition to basic service
99052 Services requested between 10:00 PM and 8:00 AM in addition to basic
service
99054 Services requested on Sundays and holidays in addition to basic service
99058 Office services provided on an emergency basis
99071 Educational supplies, such as books, tapes, and pamphlets, provided by the
physician for the patient’s education at cost to physician

99090 Analysis of information data stored in computers (e.g., ECG, blood
pressures, hematologic data)
99185 Hypothermia; regional
99371 Telephone call by a physician to patient or for consultation or medical
management or for coordinating medical management with other health
care professionals; simple or brief (e.g., to report on tests and/or laboratory
results, to clarify or alter previous instructions, to integrate new
information from other health professionals into the medical treatment
plan, or to adjust therapy)
99372 Intermediate (e.g., to provide advice to an established patient on a new
problem, to initiate therapy that can be handled by telephone, to discuss
test results in detail, to coordinate medical management of a new problem
in an established patient, to discuss and evaluate new information and
details, or to initiate a new plan of care)
99373 Complex or lengthy (e.g., lengthy counseling session with anxious or
distraught patient, detailed or prolonged discussion with family members
regarding seriously ill patient, lengthy communication necessary to
coordinate complex services or several different health professionals
working on different aspects of the total patient care plan)
• 	Anesthesia (whatever code billed)
• 	Care of Infected Skin (whatever code billed)
• 	Checking of Treatment Charts
• 	Verification of Dosage, As Needed (whatever code billed)
• 	Continued Patient Evaluation, Examination, 	Written Progress Notes, As
Needed (whatever code billed)
• 	Final Physical 	Examination (whatever code billed)
• 	Medical Prescription Writing (whatever code billed
• 	Nutritional Counseling (whatever code billed)
• 	Pain Management (whatever code billed)
• 	Review & Revision of Treatment Plan (whatever code billed)
• 	Routine Medical Management of Unrelated Problem (whatever code billed)
• 	Special Care of Ostomy (whatever code billed)
• 	Written Reports, Progress Note (whatever code billed)
• 	Follow-up Examination and Care for 90 Days After Last Treatment (whatever
code billed)
*NOTE: May be billed with Radiation Treatment Delivery, superficial and/or ortho
voltage, for the purpose of reporting physician services consisting of radiation therapy
planning (including, but not limited to clinical treatment planning, isodose planning,
physics consultation), radiation treatment device construction, and radiation treatment
management when performed on the same date of service as treatment delivery. Billing
with modifier 25 may be necessary if National Correct Coding Initiative (NCCI) edits
apply.

70.3 - Radiation Treatment Delivery (CPT 77401 - 77417)
(Rev. 1, 10-01-03)
A/B MACs (B) pay for these TC services on a daily basis under CPT codes 77401-77416
for radiation treatment delivery. They do not use local codes and RVUs in paying for the
TC of radiation oncology services. Multiple treatment sessions on the same day are
payable as long as there has been a distinct break in therapy services, and the individual
sessions are of the character usually furnished on different days. A/B MACs (B) pay for
CPT code 77417 (Therapeutic radiology port film(s)) on a weekly (five fractions) basis.
70.4 - Clinical Brachytherapy (CPT Codes 77750 - 77799)
(Rev. 1, 10-01-03)
A/B MACs (B) must apply the bundled services policy to procedures in this family of
codes other than CPT code 77776. For procedures furnished in settings in which TC
payments are made, A/B MACs (B) must pay separately for the expendable source
associated with these procedures under CPT code 79900 except in the case of remote
after-loading high intensity brachytherapy procedures (CPT codes 77781-77784). In the
four codes cited, the expendable source is included in the RVUs for the TC of the
procedures.
70.5 - Radiation Physics Services (CPT Codes 77300 - 77399)
(Rev. 1, 10-01-03)
A/B MACs (B) pay for the PC and TC of CPT codes 77300-77334 and 77399 on the
same basis as they pay for radiologic services generally. For professional component
billings in all settings, A/B MACs (B) presume that the radiologist participated in the
provision of the service, e.g., reviewed/validated the physicist’s calculation. CPT codes
77336 and 77370 are technical services only codes that are payable by A/B MACs (B) in
settings in which only technical component is are payable.
80 - Supervision and Interpretation (S&I) Codes and Interventional
Radiology
(Rev. 1, 10-01-03)
80.1 - Physician Presence
(Rev. 1, 10-01-03)
Radiologic supervision and interpretation (S&I) codes are used to describe the personal
supervision of the performance of the radiologic portion of a procedure by one or more
physicians and the interpretation of the findings. In order to bill for the supervision
aspect of the procedure, the physician must be present during its performance. This kind
of personal supervision of the performance of the procedure is a service to an individual
beneficiary and differs from the type of general supervision of the radiologic procedures
performed in a hospital for which A/B MACs (A) pay the costs as physician services to

the hospital. The interpretation of the procedure may be performed later by another
physician. In situations in which a cardiologist, for example, bills for the supervision (the
“S”) of the S&I code, and a radiologist bills for the interpretation (the “I”) of the code,
both physicians should use a “-52” modifier indicating a reduced service, e.g., only one
of supervision and/or interpretation. Payment for the fragmented S&I code is no more
than if a single physician furnished both aspects of the procedure.
80.2 - Multiple Procedure Reduction
(Rev. 1, 10-01-03)
A/B MACs (B) make no multiple procedure reductions in the S&I or primary non-
radiologic codes in these types of procedures, or in any procedure codes for which the
descriptor and RVUs reflect a multiple service reduction. For additional procedure codes
that do not reflect such a reduction, A/B MACs (B) apply the multiple procedure
reductions.
90 - Services of Portable X-Ray Suppliers
(Rev. 1, 10-01-03)
Services furnished by portable x-ray suppliers may have as many as four components.
A/B MACs (B) must follow the following rules.
90.1 - Professional Component
(Rev. 1, 10-01-03)
Pay the PC of radiologic services furnished by portable x-ray suppliers on the same basis
as other physician fee schedule services.
90.2 - Technical Component
(Rev. 1, 10-01-03)
Pay the TC of radiology services furnished by portable x-ray suppliers under the fee
schedule on the same basis as TC services generally.
90.3 - Transportation Component (HCPCS codes R0070 - R0075)
(Rev. 13150; Issued:04-11-25; Effective: 01-01-25; Implementation:05-12-25)
Transportation for portable x-ray services (HCPCS codes R0070 - R0075) is paid under
the Medicare Physician Fee Schedule and represents the transportation of the equipment
to the patient. CMS has not established national relative value units (RVUs) for these
HCPCS codes, and local RVUs for these codes are determined by each A/B Medicare
Administrative Contractor (MAC) within its respective geographic area. As a contractor
priced service, MACs must initially determine a payment rate for portable x-ray
transportation services that is associated with the cost of providing the service and
consistent with statutory requirements and as outlined in the below subsections.

90.3.1 – Periodic Review
(Rev. 13150; Issued:04-11-25; Effective: 01-01-25; Implementation:05-12-25)
MACs must periodically review (at least every five years taking into account local
conditions as appropriate) their locally determined payment amounts to consider whether
their current payment amounts reflect the relative resources (e.g., staff, equipment,
supplies and all indirect expenses) involved with performing MAC-priced services.
Portable x-ray suppliers may work with the local MACs to review payment amounts for
these services, including reporting cost data in the MAC’s requested format for their
jurisdiction(s). MACs may request additional cost data from suppliers to aid in the
periodic review process. The purpose of the MACs’ periodic review process is to obtain
reported costs from suppliers for portable x-ray transportation services within the
jurisdiction under review.
Direct costs related to the vehicle carrying the x-ray machine are fully allocable to
determining the payment rate. This includes the cost of the vehicle using a recognized
depreciation method, the salary and fringe benefits associated with the staff who drive
the vehicle, the communication equipment used between the vehicle and the home office,
the salary and fringe benefits of the staff who determine the vehicles route (vehicle fuel,
repairs and maintenance of the vehicle(s), insurance for the vehicle(s), operating
expenses for the vehicles and any other reasonable costs associated with this service.
The MAC will have discretion for allocating indirect costs (those costs that cannot be
directly attributed to portable x-ray transportation) between the transportation service
and the technical component of the x-ray tests using an established Medicare allocation
method.
The MACs must inform each supplier who submits such data that the data is subject to
verification and will be used to supplement other information that is used to determine
payment rates set by the MAC. The MACs must disclose the methodology and data
sources used to set transportation rates following a periodic review.
Suppliers are allowed ample time to respond to survey requests for use in the MAC
periodic review process. If the periodic review will adjust rates for the upcoming
calendar year, the MACs are allowed ample time to complete their review and inform
suppliers of preliminary rates before the start of the upcoming calendar year.
Mid-year adjustments are possible if the MAC believes such adjustments are appropriate
based on a review and assessment of cost information submitted by portable x-ray
suppliers. These mid-year adjustments provide MACs with the flexibility to take into
account local factors affecting the level of resources involved with performing this
service.

90.3.2 – Annual Update
(Rev. 13150; Issued:04-11-25; Effective: 01-01-25; Implementation:05-12-25)
The MACs are required to update the rate on an annual basis using independently
determined measures of the cost of providing the service. There are several readily
available measures that are used by the Medicare program to adjust payment rates for
other types of services, which are appropriate to use to update the transportation rate for
years that the MAC does not perform a periodic review. Each MAC has the flexibility to
identify the index it will use to update the rate and may consider existing adjustment
factors such as the Ambulance Inflation Factor, Medicare Economic Index, or Consumer
Price Index for all urban consumers, to reflect changes in the costs of providing services
including portable x-ray on an annual basis. In addition, the MACs can consider locally
identified factors that are measured independently of CMS as a supplement to the annual
adjustment, so long as they are reflective of changes in the costs of providing portable x-
ray transportation services.
The MAC must disclose the rationale for the index selected and, if applicable, locally
identified factors when determining the annual update amount. The MACs also must
explain whether the selected index is changing year over year and the rationale for that
change.
90.3.3 – Publishing Payment Rates
(Rev. 13150; Issued:04-11-25; Effective: 01-01-25; Implementation:05-12-25)
The MACs must issue preliminary estimated payment rates for an upcoming calendar
year at least 90 days prior to the effective date, including the rationale for the payment
rate as described in sections 90.3.1 and 90.3.2. Final payment rates must be issued by the
MACs prior to their effective date.
90.3.4 – Modifiers for Single and Multiple Patients Served at the Same
Location
(Rev. 13150; Issued:04-11-2025; Effective: 01-01-2025; Implementation:05-12-2025)
This component represents the transportation of the equipment to the patient. Establish
local RVUs for the transportation R codes based on MAC knowledge of the nature of the
service furnished. The MACs shall allow only a single transportation payment for each
trip the portable x-ray supplier makes to a particular location. When more than one
patient is x-rayed at the same location, e.g., a nursing home, prorate the single fee
schedule transportation payment among all patients (Medicare Parts A and B, and non-
Medicare) receiving the portable x-ray services during that trip, regardless of their
insurance status. For example, for portable x-ray services furnished at a Skilled Nursing

Facility (SNF), the transportation fee should be allocated among all patients receiving
portable x-ray services at the same location in a single trip irrespective of whether the
patient is in a Part A stay, a Part B patient, or not a Medicare beneficiary at all. If the
patient is in a Part A SNF stay, the transportation and set up costs are subject to
consolidated billing and not separately billable to Medicare Part B. For a privately
insured patient, it would be the responsibility of that patient’s insurer. For a Medicare
Part B patient, payment would be made under Part B for the share of the transportation
fee attributable to that patient.
R0075 must be billed in conjunction with the radiology codes and only when the x-ray
equipment used was actually transported to the location where the x-ray was taken.
R0075 would not apply to the x-ray equipment stored in the location where the x-ray was
done (e.g., a nursing home) for use as needed.
Below are the definitions for each modifier that must be reported with R0075. Only one of
these five modifiers shall be reported with R0075. NOTE: If only one patient is served,
R0070 should be reported with no modifier since the descriptor for this code reflects only
one patient seen.
UN - Two patients served
UP - Three patients served
UQ - Four patients served
UR - Five Patients served
US - Six or more patients served
Payment for the above modifiers must be consistent with the definition of the modifiers.
Therefore, for R0075 reported with modifiers, -UN, -UP, -UQ, and –UR, the total
payment for the service shall be divided by 2, 3, 4, and 5 respectively. For modifier –US,
the total payment for the service shall be divided by 6 regardless of the number of
patients served. For example, if 8 patients were served, R0075 would be reported with
modifier –US and the total payment for this service would be divided by 6.
The units field for R0075 shall always be reported as “1” except in extremely unusual
cases. The number in the units field should be completed in accordance with the
provisions of 100-04, chapter 23, section 10.2 item 24 G which defines the units field as
the number of times the patient has received the itemized service during the dates listed in
the from/to field. The units field must never be used to report the number of patients
served during a single trip. Specifically, the units field must reflect the number of services
that the specific beneficiary received, not the number of services received by other
beneficiaries.

NOTE: No transportation charge is payable unless the portable x-ray equipment used
was actually transported to the location where the x-ray was taken. For example, MACs
do not allow a transportation charge when the x-ray equipment is stored in a nursing
home for use as needed. However, a set-up payment (see §90.4, below) is payable in such
situations. Further, for services furnished on or after January 1, 1997, MACs may not
make separate payment under HCPCS code R0076 for the transportation of EKG
equipment by portable x-ray suppliers or any other entity.
90.4 - Set-Up Component (HCPCS Code Q0092)
(Rev. 1, 10-01-03)
A/B MACs (B) must pay a set-up component for each radiologic procedure (other than
retakes of the same procedure) during both single patient and multiple patient trips under
Level II HCPCS code Q0092. A/B MACs (B) do not make the set-up payment for EKG
services furnished by the portable x-ray supplier.
90.5 - Transportation of Equipment Billed by a SNF to a MAC
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15)
When a SNF bills for portable x-ray equipment transported to a site by van or other
vehicle, the SNF should bill for the transportation costs using one of the following
HCPCS codes along with the appropriate revenue code:
Code 	Description
R0070 	Transportation of Portable x-ray Equipment and Personnel to Home or
Nursing Home, Per Trip to Facility or Location, One Patient Seen.
R0075 	Transportation of Portable x-ray Equipment and Personnel to Home or
Nursing Home, Per Trip to Facility or Location, More than One Patient
Seen, Per Patient.
These HCPCS codes are subject to the fee schedule.
Effective April 1, 2006, SNFs are required to report the appropriate modifiers to identify
the number of patients served when billing for R0075. See section 90.3, of this chapter
for the list of modifiers used to identify on the claim the number of patients served.
MACs shall ensure that payment for R0075 is consistent with the definition of the
modifiers.
NOTE: When a SNF resident receives a portable x-ray service during the course of a
Medicare-covered stay in the SNF, only the service’s professional component
(representing the physician’s interpretation of the test results) is a separately billable
physician service under Part B (see §20.1 of this chapter and §20.1.1 of Chapter 6). By
contrast, the technical component representing the procedure itself, including any
associated transportation and setup costs, would be subject to consolidated billing (the

SNF “bundling” requirement for services furnished to the SNF’s Part A residents), and
must be included on the SNF’s Part A bill for the resident’s covered stay (Bill Type 21x)
rather than being billed separately under Part B (see §20.2.1of this chapter).
100 - Interpretation of Diagnostic Tests
(Rev. 1, 10-01-03)
100.1 - X-rays and EKGs Furnished to Emergency Room Patients
(Rev. 1, 10-01-03)
The professional component of a diagnostic procedure furnished to a beneficiary in a
hospital includes an interpretation and written report for inclusion in the beneficiary’s
medical record maintained by the hospital. (See 42 CFR 415.120(a).)
A/B MACs (B) generally distinguish between an “interpretation and report” of an x-ray
or an EKG procedure and a “review” of the procedure. A professional component billing
based on a review of the findings of these procedures, without a complete, written report
similar to that which would be prepared by a specialist in the field, does not meet the
conditions for separate payment of the service. This is because the review is already
included in the emergency department evaluation and management (E/M) payment. For
example, a notation in the medical records saying “fx-tibia” or EKG-normal would not
suffice as a separately payable interpretation and report of the procedure and should be
considered a review of the findings payable through the E/M code. An “interpretation
and report” should address the findings, relevant clinical issues, and comparative data
(when available).
Generally, A/B MACs (B) must pay for only one interpretation of an EKG or x-ray
procedure furnished to an emergency room patient. They pay for a second interpretation
(which may be identified through the use of modifier “-77”) only under unusual
circumstances (for which documentation is provided) such as a questionable finding for
which the physician performing the initial interpretation believes another physician’s
expertise is needed or a changed diagnosis resulting from a second interpretation of the
results of the procedure.
When A/B MACs (B) receive only one claim for an interpretation, they must presume
that the one service billed was a service to the individual beneficiary rather than a quality
control measure and pay the claim if it otherwise meets any applicable reasonable and
necessary test.
When A/B MACs (B) receive multiple claims for the same interpretation, they must
generally pay for the first bill received. A/B MACs (B) must pay for the interpretation
and report that directly contributed to the diagnosis and treatment of the individual
patient. Consideration is not given to physician specialty as the primary factor in
deciding which interpretation and report to pay regardless of when the service is
performed. Consideration is not given to designation as the hospital’s “official
interpretation” as a factor in determining which claim to pay. A/B MACs (B) pay for the

interpretation billed by the cardiologist or radiologist if the interpretation of the procedure
is performed at the same time as the diagnosis and treatment of the beneficiary. (This
interpretation may be an oral report to the treating physician that will be written at a later
time.)
If the first claim received is from a radiologist, A/B MACs (B) generally pay the claim
because they would not know in advance that a second claim would be forthcoming.
When A/B MACs (B) receive the claim from the emergency room (ER) physician and
can identify that the two claims are for the same interpretation, they must determine
whether the claim from the ER physician was the interpretation that contributed to the
diagnosis and treatment of the patient and, if so, they pay that claim. In such cases, A/B
MACs (B) must determine that the radiologist’s claim was actually quality control and
institute recovery action.
The two parties should reach an accommodation about who should bill for these
interpretations. The following examples apply to A/B MACs (B):
EXAMPLE A:
A physician sees a beneficiary in the ER on January 1 and orders a single view chest x-
ray. The physician reviews the x-ray, treats, and discharges the beneficiary. An A/B
MAC (B) receives a claim from a radiologist for CPT code 71010-26 indicating an
interpretation with written report with a date of service of January 3. The A/B MAC (B)
will pay the radiologist’s claim as the first bill received. A/B MACs (B) do not have to
develop the claim to determine whether the interpretation was a quality control service.
EXAMPLE B:
Same circumstances as Example A, except that the physician who sees the beneficiary in
the ER also bills for CPT code 71010-26 with a date of service of January 1. The A/B
MAC (B) will pay the first claim received. If the first claim is from the treating physician
in the ER, and there is no indication the claim should not be paid, e.g., no reason to think
that a complete, written interpretation has not been performed, payment of the claim is
appropriate. The A/B MAC (B) will deny a claim subsequently received from a
radiologist for the same interpretation as a quality control service to the hospital rather
than a service to the individual beneficiary.
EXAMPLE C:
Same as Example B except that the claim from the radiologist uses modifier “-77” and
indicates that, while the ER physician’s finding that the patient did not have pneumonia
was correct, there was also a suspicious area of the lung suggesting a tumor that required
further testing. In such situations, the A/B MAC (B) pays for both claims under the fee
schedule.
EXAMPLE D:

The A/B MAC (B) receives separate claims for CPT code 71010-26 from a radiologist
and a physician who treated that patient in the ER, both with a date of service of January
1. The first claim processed in the system is paid and the second claims will be identified
and denied as a duplicate. If the denied “provider” is the radiologist and he raises an
issue the A/B MAC (B) will develop the claim to determine whether the findings of the
radiologist’s interpretation were conveyed to the treating physician (orally or in writing)
in time to contribute to the diagnosis and treatment of the patient. If the radiologist’s
interpretation was furnished in time to serve this purpose, that claim should be paid, and
the claim from the other physician should be denied as not reasonable and necessary.
110 - Special Billing Instructions for Claims Submitted to A/B MACs
(A)
(Rev. 1, 10-01-03)
Transmittal 368 (CR 1323 issued May 24-01) which revised the following SNF sections
of the manual but not incorporated in the master manual.
SNF-533.1, SNF-533.1.A, SNF-533.1.B, SNF-533.1.C, SNF-533.1.D, SNF-533.1.E
For billing instructions, see chapter 25.
110.1 - Aborted Procedure
(Rev. 1, 10-01-03)
When a procedure is not completed, the SNF should bill an unlisted code (e.g., CPT code
ending in 99) and show the actual charges for the procedure. The A/B MAC (A) will
request additional data from the SNF to determine applicable payment. Deductible and
coinsurance apply based on fee schedule rules.
110.2 - Combined Procedures (Radiology)
(Rev. 1, 10-01-03)
There are no separate codes covering certain combined procedures, e.g., a hand and
forearm included in a single x-ray. The code with the higher fee schedule amount should
be used.
110.2 - Combined Procedures (Radiology)
(Rev. 1, 10-01-03)
There are no separate codes covering certain combined procedures, e.g., a hand and
forearm included in a single x-ray. The code with the higher fee schedule amount should
be used.
110.3 - Payment for Radiopharmaceuticals

(Rev. 1, 10-01-03)
Radiopharmaceuticals are not subject to the fee schedule, but are paid based on
reasonable cost when given in a SNF. SNFs report HCPCS codes 79900, A4641, A4642,
A9500, A9503, and A9505, as appropriate, with revenue codes 0333, 034X, or 0636.
NOTE: The correct code to report is A4641. It replaced HCPCS code 78990. HCPCS
code 78990 should not be reported because this code is not valid for Medicare purposes.
EXCEPTION: HCPCS codes 77781, 77782, 77783, and 77784 include payment for the
radiopharmaceutical in the technical component. When these procedures are performed,
SNFs do not report radiopharmaceutical codes 79900, A4641, A4642, A9500, A9503,
and A9505. The A/B MAC (A) will reject codes 79900, A4641, A4642, A9500, A9503,
and A9505 when they are billed for supplies used in conjunction with procedure codes
77781, 77782, 77783, and 77784.
120 - Radiology or Other Diagnostic Unlisted Service or Procedure
Billing Instructions for A/B MAC (A) Claims
(Rev. 1, 10-01-03)
Some radiology and other diagnostic services may not have a corresponding HCPCS
code. This is because these are typically services that are rarely provided, unusual, or
new. The provider should assign the appropriate “unlisted procedure” code to any such
service. The following list contains the “unlisted procedure” codes along with the
suggested revenue code for billing. These services are paid on a fee schedule if one
exists or cost if a fee has not been established for SNFs. However, before billing any of
these codes the provider needs to furnish a complete description of the radiology
procedure to the A/B MAC (A) for review and analysis. The description should include a
narrative definition of the procedure and a description of the nature, extent and need for
the procedure and the time, effort, and equipment necessary. The A/B MAC (A) will
determine if the provider has correctly identified the procedure as “unlisted.” If the
procedure is not identified correctly, the A/B MAC (A) will inform the provider of the
correct HCPCS code to assign to the procedure. If there is no fee schedule amount
established, these services are paid based on cost to SNFs.
For Radiology:
Revenue Code 	HCPCS 	Definition
032x 	76499 	Unlisted diagnostic radiologic procedure
0402 	76999 	Unlisted ultrasound procedure
0333 	77299 	Unlisted procedure, therapeutic radiology clinical
treatment planning

Revenue Code 	HCPCS 	Definition
0333 	77399 	Unlisted procedure, medical radiation physics, dosimetry
and treatment devices
0333 	77499 	Unlisted procedure, therapeutic radiology clinical
treatment management
0333 	77799 	Unlisted procedure, clinical brachytherapy
034x 	78099 	Unlisted endocrine procedure, diagnostic nuclear medicine
034x 	78199 	Unlisted hematopoietic, reticuloendothelial and lymphatic
procedure, diagnostic nuclear medicine
034x 	78299 	Unlisted gastrointestinal procedure, diagnostic nuclear
medicine
034x 	78399 	Unlisted musculoskeletal procedure, diagnostic nuclear
medicine
034x 	78499 	Unlisted cardiovascular procedure, diagnostic nuclear
medicine
034x 	78599 	Unlisted respiratory procedure, diagnostic nuclear
medicine
034x 	78699 	Unlisted nervous system procedure, diagnostic nuclear
medicine
034x 	78799 	Unlisted genitourinary procedure, diagnostic nuclear
medicine
034x 	78999 	Unlisted miscellaneous procedure, diagnostic nuclear
medicine
034x 	79999 	Unlisted radiopharmaceutical therapeutic procedure
For Other Diagnostic Procedures:
Revenue Code 	HCPCS 	Definition
075x 	91299 	Unlisted diagnostic gastroenterology procedure
047x 	92599 	Unlisted otorhinolaryngological service or procedure
048x 	93799 	Unlisted cardiovascular service or procedure

Revenue Code 	HCPCS 	Definition
073x 	93799 	Unlisted cardiovascular service or procedure
0921 	93799 	Unlisted cardiovascular service or procedure
046x 	94799 	Unlisted pulmonary service or procedure
074x 	95999 	Unlisted neurological or neuromuscular diagnostic
procedure
0922 	95999 	Unlisted neurological or neuromuscular diagnostic
procedure
130 - EMC Formats
(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid
Tumors: June 11, 2013, ICD-10: Upon Implementation of ICD-10
Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron
Emission Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared
System Edits; July 7, 2014 - CWF development/testing, FISS requirement
development; October 6, 2014 - CWF, FISS, MCS Shared System Edits), ICD-10:
Upon Implementation of ICD-10)
Billing instructions for the ASC X12 837 institutional claim format can be found in
chapter 24 of this manual or, for Form CMS-1450 can be found in chapter 25 of this
manual. Each revenue code requires a HCPCS code, modifier if applicable, units, line-
item date of service, and charge.
Billing instructions for the ASC X12 837 professional claim format can be found in
chapter 24 of this manual or for Form CMS-1500 can be found in this manual, Chapter
26, “Instructions for Completing Form CMS-1500."
140 - Bone Mass Measurements (BMMs)
(Rev. 1416; Issued: 01-18-08; Effective: 01-01-07; Implementation: 02-20-08)
Sections 1861(s)(15) and (rr)(1) of the Social Security Act (the Act) (as added by §4106
of the Balanced Budget Act (BBA) of 1997) standardize Medicare coverage of medically
necessary bone mass measurements by providing for uniform coverage under Medicare
Part B. This coverage is effective for claims with dates of service furnished on or after
July 1, l998.
Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee
Schedule final rule expanded the number of beneficiaries qualifying for BMM by
reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of
prednisone per day to 5.0 mg. It also changed the definition of BMM by removing

coverage for a single-photon absorptiometry as it is not considered reasonable and
necessary under section 1862 (a)(1)(A) of the Act. Finally, it required that in the case of
monitoring and confirmatory baseline BMMs, they be performed with a dual-energy x-
ray absorptiometry (axial) test.
Conditions of Coverage for BMMs are located in Pub.100-02, Medicare Benefit Policy
Manual, chapter 15
140.1 - Payment Methodology and HCPCS Coding
(Rev. 4150, Issued: 10-26-2018, Effective: 04-01-19, Implementation: 04-01-19)
A/B MACs (B) pay for BMM procedures based on the Medicare physician fee schedule.
Claims from physicians, other practitioners, or suppliers where assignment was not taken
are subject to the Medicare limiting charge.
The A/B MACs (A) pay for BMM procedures under the current payment methodologies
for radiology services according to the type of provider.
Do not pay BMM procedure claims for dual photon absorptiometry, CPT procedure code
78351.
Deductible and coinsurance do not apply.
Any of the following CPT procedure codes may be used when billing for BMMs through
December 31, 2006. All of these codes are bone densitometry measurements except code
76977, which is bone sonometry measurements. CPT procedure codes are applicable to
billing A/B MACs (A and B).
76070 76071 76075 76076 76078 76977 78350 G0130
Effective for dates of services on and after January 1, 2007, the following changes apply
to BMM:
New 2007 CPT bone mass procedure codes have been assigned for BMM. The following
codes will replace current codes, however the CPT descriptors for the services remain the
same:
77078 replaces 76070
77079 replaces 76071
77080 replaces 76075
77081 replaces 76076
77083 replaces 76078

Effective for dates of service on and after January 1, 2015, contractors shall pay
for bone mass procedure code 77085 (Dual-energy X-ray absorptiometry (DXA),
bone density study, 1 or more sites, axial skeleton, (e.g., hips, pelvis, spine),
including vertebral fracture assessment.)
Certain BMM tests are covered when used to screen patients for osteoporosis subject to
the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit
Policy Manual.
Contractors will pay claims for screening tests when coded as follows:
Contains CPT procedure code 77078, 77079, 77080, 77081,
77083, 76977 or G0130, and
Contains a valid diagnosis code indicating the reason for the test is
postmenopausal female, vertebral fracture, hyperparathyroidism, or
steroid therapy. Contractors are to maintain local lists of valid
codes for the benefit’s screening categories.
Contractors will deny claims for screening tests when coded as follows:
Contains CPT procedure code 77078, 77079, 77081, 77083, 76977
or G0130, but
Does not contain a valid diagnosis code from the local lists of valid
diagnosis codes maintained by the contractor for the benefit’s
screening categories indicating the reason for the test is
postmenopausal female, vertebral fracture, hyperparathyroidism, or
steroid therapy.
Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-
approved osteoporosis drug therapy subject to the 2-year frequency standards described
in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual.
Contractors will pay claims for monitoring tests when coded as follows:
Contains CPT procedure code 77080 or 77085, and
Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as
the ICD-9-CM diagnosis code or M81.0, M81.8, M81.6 or M94.9
as the ICD-10-CM diagnosis code.
Contractors will deny claims for monitoring tests when coded as follows:
Contains CPT procedure code 77078, 77079, 77081, 77083, 76977
or G0130, and
Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0
as the ICD-9-CM diagnosis code, but

Does not contain a valid ICD-9-CM diagnosis code from the local
lists of valid ICD-9-CM diagnosis codes maintained by the
contractor for the benefit’s screening categories indicating the
reason for the test is postmenopausal female, vertebral fracture,
hyperparathyroidism, or steroid therapy.
Does not contain a valid ICD-10-CM diagnosis code from the local
lists of valid ICD-10-CM diagnosis codes maintained by the
contractor for the benefit’s screening categories indicating the
reason for the test is postmenopausal female, vertebral fracture,
hyperparathyroidism, or steroid therapy.
Single photon absorptiometry tests are not covered. Contractors will deny CPT
procedure code 78350.
The A/B MACs (A) are billed using the ASC X12 837 institutional claim format or
hardcopy Form CMS-1450. The appropriate bill types are: 12X, 13X, 22X, 23X, 34X,
71X (Provider-based and independent), 72X, 77X (Provider-based and freestanding),
83X, and 85X. Effective April 1, 2006, type of bill 14X is for non-patient laboratory
specimens and is no longer applicable for bone mass measurements. Information
regarding the claim form locators that correspond to the HCPCS/CPT code or Type of
Bill are found in chapter 25.
Providers must report HCPCS codes for bone mass measurements under revenue code
320 with number of units and line item dates of service per revenue code line for each
bone mass measurement reported.
A/B MACs (B) are billed for bone mass measurement procedures using the ASC X12
837 professional claim format or hardcopy Form CMS-1500.
140.2 - Denial Messages for Noncovered Bone Mass Measurements
(Rev. 3650, Issued: 11-10-16, Effective: 02-10-17, Implementation: 02-10-17)
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under the conditions described in 140.1. This
CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.
Group Code: PR (if claim is received with a GA modifier) otherwise CO
CARC: 50
RARC: Alert M38 (if ABN was issued) or M27 (if ABN was not issued)
MSN: 16.10 and 36.1 (if ABN was issued) or 36.2 (if ABN was not issued)
NOTE: A/B MACs (A) are not to include MSN 16.10.

140.4 – Advance Beneficiary Notices (ABNs)
(Rev. 1236, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
For the denial situations listed in Section 140.1, physicians, practitioners and hospitals
are liable for payment unless they issue an appropriate ABN. Contractors will utilize the
appropriate messages, see sections 140.2 and 140.3.
150 - Place of Service (POS) Instructions for the Professional
Component (PC or Interpretation) and the Technical Component (TC)
of Diagnostic Tests
(Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)
Many of the diagnostic services, including radiology services, provided by
physicians/practitioners contain both a technical component (TC) and a professional
component (PC). Often, the PC and TC of diagnostic services are furnished in different
settings. As a general policy, the POS code assigned by the physician/practitioner for the
PC of a diagnostic service shall be the setting in which the beneficiary received the TC
service.
A. Interpretation Provided Telephonically by Wireless Remote
Teleradiology services (radiology services that do not require a face-to-face encounter
with the patient furnished through the use of a telecommunications system) are discussed
in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 30. The
interpretation of an x-ray, electrocardiogram, electroencephalogram and tissue samples
are listed as examples of these services.
In cases where the face-to-face requirement is obviated such as those when a
physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant
site, the POS code assigned by the physician /practitioner shall be the setting in which the
beneficiary received the TC service. The POS code for a teleradiology interpretation is
generally the place where the beneficiary received the TC, or face-to-face encounter. The
POS code representing the setting where the beneficiary received the TC is entered in the
ASC X12 837 professional claim format or in item 24B on the paper claim Form CMS
1500. In cases where it is unclear which POS code applies, the Medicare contractor can
provide guidance.
For example: A beneficiary receives an MRI on an outpatient hospital campus near
his/her home. The outpatient hospital submits a claim that would correspond to the TC
portion of the MRI. The physician furnishes the PC portion of the beneficiary’s MRI
from his/her office location - POS code 22 (On Campus-Outpatient Hospital) shall be
used on the physician’s claim to indicate that the beneficiary received the face-to-face
portion of the MRI, the TC, on the campus of an outpatient hospital.
B. Interpretation Provided Outside of the United States

Generally, Medicare will not pay for health care or supplies that are performed outside
the United States (U.S.). The term “outside the U.S.” means anywhere other than the 50
states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam,
American Samoa, and the Northern Mariana Islands. See Pub. 100-02, chapter 16,
section 60, for exceptions to the “outside the U.S.” exclusions.
C. Interpretation Provided Under Arrangement - To A Hospital
Separate TC and PC
If a diagnostic test which has a separate TC and PC is provided under arrangement to a
hospital, the physician who reads the test can bill and be paid for the professional
component. Both the technical and professional components of the test are also subject
to the physician self-referral prohibition.
The appropriate POS code for the interpretation (or PC) is the setting where the
beneficiary received the TC service. If the interpretation is performed in the physician’s
office and the patient received the TC service in the provider-based outpatient hospital
setting, the physician assigns POS code 22, for On Campus-Outpatient Hospital, or POS
19, for Off Campus-Outpatient Hospital, on the claim for the interpretation or PC.
Global Service
When a physician performs a diagnostic test under arrangement to a hospital and the test
and the interpretation are not separately billable, the interpretation cannot be billed by the
physician. In this scenario, the hospital is the only entity that can bill for the diagnostic
test which encompasses the interpretation. There is no POS code for the interpretation
since a physician claim is not generated.
D. Global Billing
Billing globally for services that are split into PC and TC components is only possible
when the TC and the physician who provides the PC of the diagnostic service are
furnished by the same physician or supplier entity and the PC and TC components are
furnished within the same Medicare physician fee schedule payment locality. Merely
applying the same POS code to the PC as that of the TC (as described in “A” above) does
not permit global billing for any diagnostic procedure.
E. Determination of Payment Locality
Under the Medicare physician fee schedule (MPFS), payment amounts are based on the
relative resources required to provide services and vary among payment localities as
resource costs vary geographically as measured by the geographic practice cost indices
(GPCIs). The payment locality is determined based on the location where a specific
service code was furnished. For purposes of determining the appropriate payment

locality, CMS requires that the address, including the ZIP code for each service code be
included on the claim form in order to determine the appropriate payment locality. The
location in which the service code was furnished is entered on the ASC X12 837
professional claim format or in Item 32 on the paper claim Form CMS 1500.
Global Service Code
If the global diagnostic service code is billed, the biller (either the entity that took the test,
physician who interpreted the test, or separate billing agent) must report the address and
ZIP code of where the test was furnished on the bill for the global diagnostic service
code. In other words, when the global diagnostic service code is billed, for example,
chest x-ray as described by HCPCS code 71010 (no modifier TC and no modifier -26),
the locality is determined by the ZIP code applicable to the testing facility, i.e. where the
TC of the chest x-ray was furnished. The testing facility (or its billing agent) enters the
address and ZIP code of the setting/location where the test took place. This practice
location is entered using the ASC X12 837 professional claim format or in Item 32 on the
paper claim Form CMS 1500. As explained in D above, in order to bill for a global
diagnostic service code, the same physician or supplier entity must furnish both the TC
and the PC of the diagnostic service and the TC and PC must be furnished within the
same MPFS payment locality.
Separate Billing of Professional Interpretation
If the same physician or other supplier entity does not furnish both the TC and PC of the
diagnostic service, or if the same physician or other supplier entity furnishes both the TC
and PC but the professional interpretation was furnished in a different payment locality
from where the TC was furnished, the professional interpretation of a diagnostic test must
be separately billed with modifier -26 by the interpreting physician.
When the physician’s interpretation of a diagnostic test is billed separately from the
technical component, as identified by modifier -26, the interpreting physician (or his or
her billing agent) must report the address and ZIP code of the interpreting physician’s
location on the claim form. If the professional interpretation was furnished at an unusual
and infrequent location for example, a hotel, the locality of the professional interpretation
is determined based on the Medicare enrolled location where the interpreting physician
most commonly practices. The address and ZIP code of this practice location is entered
using the ASC X12 837 professional claim format or in Item 32 on the paper claim Form
CMS 1500.

Transmittals Issued for This Chapter
Rev # 	Issue Date Subject 	Impl Date 	CR#
R13150CP 04/11/2025 Internet Only Manual (IOM) Update to 100-
04 Chapter 13, Section 90.3 - Transportation
Component (HCPCS Codes R0070 - R0075)
and Chapter 23, Section 30.5 - Payment
Amounts for Portable X-Ray Transportation
Services
05/12/2025 	13909
R12364CP 11/16/2023 NCD 220.6.20 - Beta Amyloid Positron
Emission Tomography in Dementia and
Neurodegenerative Disease
12/19/2023 	13429
R11021CP 10/01/2021 Revisions To Chapters 13, 18 And 32 To
Update Coding
10/29/2021 	12376
R10881CP 08/06/2021 REVISIONS TO CHAPTERS 13 AND 32
TO UPDATE CODING
09/07/2021 	12069
R4267CP 	03/27/2019 Evaluation and Management (E/M) when
Performed with Superficial Radiation
Treatment
03/25/2019 	11137
R4246CP 	02/22/2019 Evaluation and Management (E/M) when
Performed with Superficial Radiation
Treatment– Rescinded and replaced by
Transmittal 4267
03/25/2019 	11137
R4150CP 	10/26/2018 Update to Bone Mass Measurements (BMM)
Code 77085 Deductible and Coinsurance
04/01/2019 	10956
R3911CP 	11/09/2017 New Positron Emission Tomography (PET)
Radiopharmaceutical/Tracer Unclassified
Codes
12/11/2017 	10319
R3820CP 	07/28/2017 Payment Reduction for X-Rays Taken Using
Computed Radiography
01/02/2018 	10188
R3650CP 	11/10/2016 Updates to Pub. 100-04, Chapters 8, 13 and
14 to Correct Remittance Advice Messages
02/10/2016 	9841
R3387CP 	10/30/2015 Billing of the Transportation Fee by Portable
X-ray Suppliers
01/01/2016 	9354

Rev # 	Issue Date Subject 	Impl Date 	CR#
R3315CP 	08/06/2015 New and Revised Place of Service Codes
(POS) for Outpatient Hospital
01/04/2016 	9231
R3230CP 	04/03/2015 Updates to the Medicare Internet-Only
Manual Chapters for Skilled Nursing Facility
(SNF) Providers
06/15/2015 	8997
R3227CP 	04/02/105 	Update to Pub. 100-04 Chapter 13 to Provide
Language-Only Changes for Updating ICD-
10 and ASC X12
11/04/2014 	8614
R3216CP 	03/13/2015 Updates to the Medicare Internet-Only
Manual Chapters for Skilled Nursing Facility
(SNF) Providers – Rescinded and replaced
by Transmittal 3230
06/15/2015 	8997
R3091CP 	10/08/2014 Update to Pub. 100-04 Chapter 13 to Provide
Language-Only Changes for Updating ICD-
10 and ASC X12 – Rescinded and replaced
by Transmittal 3227
11/04/2014 	8614
R2932CP 	04/18/2014 Fluorodeoxyglucose (FDG) Positron
Emission Tomography (PET) for Solid
Tumors (This CR rescinds and fully replaces
CR8468/TR2873 dated February 6, 2014)
05/19/2014 	8739
R2898CP 	03/07/2014 Update to Pub. 100-04 Chapter 13 to Provide
Language-Only Changes for Updating ICD-
10 and ASC X12 – Rescinded and replaced
by Transmittal 3091
10/01/2014 	8614
R2873CP 	02/06/2014 Fluorodeoxyglucose (FDG) Positron
Emission Tomography (PET) for Solid
Tumors – Rescinded and replaced by CR
8739, Transmittal 2932
03/07/2014 	8468
R2750CP 	08/02/2013 Positron Emission Tomography 	09/03/2013 	8381
R2679CP 	03/29/2013 Revised and Clarified Place of Service (POS)
Coding Instructions
04/01/2013 	7631

Rev # 	Issue Date Subject 	Impl Date 	CR#
R2613CP 	12/14/2012 Revised and Clarified Place of Service (POS)
Coding Instructions – Rescinded and
replaced by Transmittal 2679
04/01/2013 	7631
R2563CP 	10/11/2012 Revised and Clarified Place of Service (POS)
Coding Instructions – Rescinded and
replaced by Transmittal 2613
04/01/2013 	7631
R2561CP 	09/28/2012 Revised and Clarified Place of Service (POS)
Coding Instructions – Rescinded and
replaced by Transmittal 2563
04/01/2013 	7631
R2435CP 	03/29/2012 Revised and Clarified Place of Service (POS)
Coding Instructions – Rescinded and
replaced by Transmittal 2561
10/01/2012 	7631
R2407CP 	02/03/2012 Revised and Clarified Place of Service (POS)
Coding Instructions – Rescinded and
replaced by Transmittal 2435
04/02/2012 	7631
R2307CP 	09/22/2011 Magnetic Resonance Imaging (MRI) in
Medicare Beneficiaries with FDA-Approved
Implanted Permanent Pacemakers (PMs) for
Use in an MRI Environment
09/26/2011 	7441
R2293CP 	08/26/2011 Magnetic Resonance Imaging (MRI) in
Medicare Beneficiaries with FDA-Approved
Implanted Permanent Pacemakers (PMs) for
Use in an MRI Environment – Rescinded and
replaced by Transmittal 2307
09/26/2011 	7441
R2171CP 	03/04/2011 Magnetic Resonance Imaging (MRI) in
Medicare Beneficiaries with Implanted
Permanent Pacemakers (PMs) or Implantable
Cardioverter Defibrillators (ICDs)
04/04/20111 7296
R2096CP 	11/19/2010 Billing Clarification for Positron Emission
Tomography (Sodium Flouride-18) (NaF-18)
PET for Identify Bone Metastasis of Cancer
in Context of a Clinical Trial
02/22/2011 	7125
R1998CP 	07/09/2010 Magnetic Resonance Angiography (MRA) 	08/09/2010 	7040

Rev # 	Issue Date Subject 	Impl Date 	CR#
R1937CP 	03/26/2010 Positron Emission Tomography (NaF-18) to
Identify Bone Mestastasis of Cancer
07/06/2010 	6861
R1931CP 	03/12/2010 Revision of the Internet Only Manual (IOM)
to Remove References to “Purchased
Diagnostic Test” and Replace With
Language Consistent With the Anti-Markup
Rule
06/14/2010 	6627
R1888CP 	01/06/2010 Positron Emission Tomography (PET)
(FDG) for Cervical Cancer
01/04/2010 	6753
R1879CP 	12/18/2009 Positron Emission Tomography (PET)
(FDG) for Cervical Cancer - Rescinded and
replaced by Transmittal 1888
01/04/2010 	6753
R1866CP 	12/04/2009 Positron Emission Tomography (PET)
(FDG) for Cervical Cancer - Rescinded and
replaced by Transmittal 1879
01/04/2010 	6753
R1833CP 	10/16/2009 FDG PET for Solid Tumors and Myeloma 	10/30/2009 	6632
R1831CP 	10/16/2009 Magnetic Resonance Imaging (MRI) 	01/04/2010 	6672
R1817CP 	09/18/2009 FDG PET for Solid Tumors and Myeloma -
Rescinded and replaced by Transmittal 1833
10/19/2009 	6632
R1782CP 	07/30/2009 Section 148 of the Medicare Improvements
for Patients and Providers Act (MIPPA)
07/06/2009 	6395
R1772CP 	07/17/2009 FDG PET for Solid Tumors and Myeloma
and Additional Manual Updates – Rescinded
and replaced by CR 6632, Transmittal 1817
08/17/2009
and
10/05/2009
6464
R1729CP 	05/08/2009 Section 148 of the Medicare Improvements
for Patients and Providers Act (MIPPA) -
Rescinded and replaced by Transmittal 1782
07/06/2009 	6395
R1472CP 	03/06/2008 Update of Institutional Claims References 	04/07/2008 	5893
R1421CP 	01/25/2008 Update of Institutional Claims References -
Rescinded and Replaced by Transmittal 1472
04/07/2008 	5893

Rev # 	Issue Date Subject 	Impl Date 	CR#
R1416CP 	01/18/2008 Clarification of Bone Mass Measurement
(BMM) Billing Requirements
02/20/2008 	5847
R1339CP 	09/21/2007 Magnetic Resonance Imaging (MRI)
Procedures
10/22/2007 	5677
R1301CP 	07/20/2007 Revised Information on PET Scan Coding 	01/07/2008 	5665
R1236CP 	05/11/2007 Bone Mass Measurements (BMMs) 	07/02/2007 	5521
R1221CP 	04/18/2007 Common Working File (CWF) Duplicate
Claim Edit for the Technical Component
(TC) of Radiology and Pathology Laboratory
Services Provided to Hospital Patients
04/02/2007 	5347
R1098CP 	11/02/2006 Common Working File (CWF) Duplicate
Claim Edit for the Technical Component
(TC) of Radiology and Pathology Laboratory
Services Provided to Hospital Patients
Replace by Transmittal 1221
04/02/2007 	5347
R956CP 	05/19/2006 Payment for Position Emission Tomography 	06/19/2006 	5124
R923CP 	04/28/2006 Update of Radiopharmaceutical Imaging
Agents HCPCS Codes Applicable to PET
Scan Services for Carriers
08/01/2006 	5054
R822CP 	02/01/2006 Update of Radiopharmaceutical Imaging
Agents HCPCS Codes Applicable to PET
Scan Services
07/03/2006 	4270
R795CP 	12/30/2005 Redefined Type of Bill 14 X for Non-Patient
Laboratory Specimens
04/03/2006 	4208
R716CP 	10/21/2005 Modifiers for Transportation of Portable X-
rays (R0075) When Billed by Skilled
Nursing Facilities (SNFs)
04/03/2006 	4039
R628CP 	07/29/2005 Radiopharmaceutical Diagnostic Imaging
Agents Codes Applicable to PET Scan
Services Performed on or After January 28,
2005
10/31/2005 	3945

Rev # 	Issue Date Subject 	Impl Date 	CR#
R627CP 	07/29/2005 New Low Osmolar Contrast Material
(LOCM) HCPCS Codes/Payment
Criteria/Payment Level
10/31/2005 	3902
R527CP 	04/15/2005 New Coding for FDG PET Scans and Billing
Requirements for Specific Indications of
Cervical Cancer
04/18/2005 	3741
R501CP 	03/11/2005 Bone Mass Measurements - Procedure
Coding
04/11/2005 	3719
R428CP 	01/14/2005 Update to Billing Requirements for FDG-
PET Scans for Use in the Differential
Diagnosis of Alzheimer's Disease (AD) and
Fronto-Temporal Dementia (FTD) and
Update to the FI Billing Requirements for
Special Payment Procedures for ALL PET
Scan Claims for Services Performed in a
Critical Access Hospital (CAH)
04/04/2005 	3640
R343CP 	10/29/2004 Clarification: Modifiers for Transportation of
Portable X-rays (R0075)
04/04/2005 	3280
R310CP 	10/01/2004 Billing Requirements for Positron Emission
Tomography (PET) Scans for Dementia and
Neurodegenerative Diseases
10/04/2004 	3426
R223CP 	07/02/2004 PET Scans and Related Claims Processing 	N/A 	3304
R135CP 	04/02/2004 Purchased Diagnostic Test - Carriers 	N/A 	1658
R001CP 	10/01/2003 Initial Publication of Manual 	NA 	NA
Back to top of Chapter