HOW TO ORDER A PET/CT
WITH ICD-10

1. ORDER FORM

Procedure Name and CPT Code

  • 78814 – AMYVID Scans
  • 78815 – Standard Body (most commonly used)
  • 78816 – Whole Body (primarily used for melanoma, sarcoma, PET bone scan, etc.)
  • 78608 – Metabolic Evaluation of the Brain

Primary Diagnosis Code

  • ICD – 10 only
  • Select code most specific to patient’s condition AND location/area of the body
  • Clinical indications for scan (diagnosing, staging, restaging, treatment monitoring or radiation treatment planning)
  • If indication is not pathology proven, please note the clinical signs and symptoms to support the reason for the scan

Provider Signature/NPI Number

Date/Time of Patient’s Follow Up

2. PATIENT’S DEMOGRAPHICS

3. PATIENT’S INSURANCE CARD

  • Primary and secondary insurance, if applicable
  • Front and back

4. CLINICAL NOTES

  • Most recent provider note
  • Recent imaging (please have patient bring CD, if available)
  • Pathology, if applicable