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PET Scans for Oncologic Conditions: Personal History

Published on 

Tuesday, May 7, 2019

 | RAC Information 
 | FAQ 

Q:

Our claims for FDG PET scans are being denied when reported with a personal history diagnosis code, Z85.XXX. Why is this happening?



A:

CMS Transmittal 2200 (CR 10859) added the following note concerning PET scans for oncologic conditions (NCD 220.6.17) when reported with a personal history diagnosis:

“Note: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D or R diagnosis codes.”

The transmittal referenced above includes a link to the NCD spreadsheet updates for the PET Scan diagnosis codes. You can find the updated list of covered diagnosis codes for PET scans and all other NCD ICD-10 code updates at the Medicare coverage ICD-10 webpage.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.