Procedure Name and CPT Code

• 78814 – Beta-Amyloid 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