CMS-10152 NOPR_PET_complete_form

PET Completion Form
National Oncologic PET Registry
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This form is completed by the PET Facility via Web-based data entry within 14 days of case registration.
The PET scan must be completed within 14 days of case registration. If the case was registered more than 14 days
prior to the PET scan the patient must be re-registered. The original case will be cancelled and the $50 will be
refunded.

PET FACILITY ID #: __________________
REGISTRY CASE #: __________________
1. DATE SCAN COMPLETED: _____/_____/_____
(must be within 14 days of registration)

2. Scan Type (you must check one)

PET

PET-CT

3. Region(s) Scanned (you must check only one)

Body Only
(Study will be billed using one of the following CPT Codes: 78811-78816. Select this entry even if
the brain was intentionally or incidentally included in a body PET imaging study.)

DEDICATED Brain Only
(Study was performed with a brain acquisition protocol and will be billed using CPT Code 78608.)

Both DEDICATED Body AND Brain
(Brain study was performed with a brain acquisition protocol and will be billed using CPT Code
78608 AND body study was performed and will be billed using one of the following CPT Codes:
78811-78816.)
4. SCANNER INFORMATION
Facility’s Scanner Identifier (facility’s name for scanner) - Pull Down Menu of Facility’s Scanner Info
5. NAME OF PERSON SUBMITTING THIS FORM
First Name: ________________ Last Name: __________________

Date

(auto filled)

Version: 05/24/07