Additional Information Provided by Empire Medicare Services

Claims meeting the above guidelines for FDG PET scan, NOT in a clinical trial setting, must be reported as follows:

• Report with HCPCS code G0336
• Report with ICD-9-CM code:

331.0 (Alzheimer’s disease)
OR
331.19 (Other frontotemporal dementia)

Claims meeting the above guidelines for FDG PET scan in a clinical trial setting must be reported as follows:

• Report with HCPCS code G0336
• Report with the Modifier QV
• Enter CMS’s approved facility name in Items 32 and 33 of the CMS-1500 claim form
• A primary and secondary ICD-9-CM code are required.

Report with one of the following primary ICD-9-CM codes:

• 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance)
   
  OR

• 294.11 (Dementia in conditions classified elsewhere with behavioral disturbance)

AND the secondary ICD-9-CM code:

• V70.7 (examination of participant in clinical trial)

Posted: 10/25/2004