POSITRON EMISSION TOMOGRAPHY (PET)



POSITRON EMISSION TOMOGRAPHY (PET)

SCANNER SERVICE DATA VERIFICATION

Michigan Department of Health and Human Services

CERTIFICATE OF NEED

South Grand Building, 4th Floor

P.O. Box 30195

Lansing, Michigan 48909

Phone: (517) 241-3344 – Fax: (517) 241-2962

| AUTHORITY: PA 368 of 1978, as amended |The Department of Health and Human Services is an equal opportunity employer,|

|COMPLETION: Is voluntary, but is required to obtain a |services and programs provider. |

|Certificate of Need. If not completed, a | |

|Certificate of Need will not be issued. | |

|Indicate the most recent 12-month period being reported for all categories: |

|From:       To:       |

IMPORTANT:

• This form must be completed by each hospital allocating data to a specific CON application.

• Leave shaded areas blank.

|Name of Hospital |

|      |

|Address (Number and Street) |City |State |ZIP Code |

|      |      |   |      |

|CON Number |Facility License Number |

|      |      |

|Has this hospital previously authorized the allocation of MIDB data to |If YES, indicate the CON number(s) below and the date on which each approved |

|another CON application(s) for PET services? |PET service became operational. |

|NO YES | |

|CON Number |Date PET Service Initiated |CON Number |Date PET Service Initiated |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|SITE CODES, MORPHOLOGY CODES, OR |Number of Verified |Approved |PET Data Units |

|MAJOR ICD-9 and ICD-10-CM CODE GROUP |Cases |Utilization | |

| | |Weights | |

| | |(Multiply) | |

|1. Combined Cancer Cases: |      |0.8 |      |

|C340-C349, C150-C159, C180-C209, M9590-9729, | | | |

|M8720-8790, C000-C148, C300-C329, C410, C411, | | | |

|C470 or C490 excluding C440-C444 | | | |

|TOTAL Combined Cancer PET Data Units |2.5 |      |

|(Item 1 PET Data Units times 2.5) ( | | |

|2. Breast Cancer Cases: |      |0.25 |      |

|C500-C509 | | | |

|TOTAL Breast PET Data Units (Item 2 PET Data Units times 1.0) ( |1.0. |      |

|3. Diagnostic Cardiac Catheterization Sessions: |      |0.1 |      |

|TOTAL Cardiac Catheterization PET Data Units |1.0. |      |

|(Item 3 PET Data Units times 1.0) ( | | |

|4. ICD-9-CM Codes for Intractable Epilepsy Procedures: |      |1.0 |      |

|(See Appendix A for ICD-10-CM Codes) | | | |

|345.01, 345.11, 345.41, 345.51, 345.61, 345.71,345.81, or 345.91 | | | |

|TOTAL Intractable Epilepsy PET Data Units (Item 4 PET Data Units times 1.0) ( |1.0. |      |

|5a. Total from Item 1 (Total Combined Cancer PET Data Units) ( |      |

|5b. Total from Item 2 (Total Breast PET Data Units) ( |      |

|5c. Total from Item 3 (Total Diagnostic Catheterization PET Data Units) ( |      |

|5d. Total from Item 4 (Total Intractable Epilepsy Cancer PET Data Units) ( |      |

|5e. TOTAL NUMBER OF PET DATA UNITS (Sum of items 5a – 5d) ( |      |

For Planning Area 6 Only:

|6. TOTAL NUMBER OF PET DATA UNITS (Line 5e times 3.0) ( |      |

For Planning Area 5 Only:

|7. For Planning Area 5 Only: |      |

|TOTAL NUMBER OF PET DATA UNITS (Line 5e times 2.0) ( | |

|Signature of MDHHS Verifier (Blue Ink) Date |Printed Name of MDHHS Verifier |

| |      |

APPENDIX A

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|345.01 |intractable epilepsy cases |G40.311 |Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus |

| | |G40.319 |Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus |

| | |G40.A11 |Absence epileptic syndrome, intractable, with status epilepticus |

|345.11 |intractable epilepsy cases |G40.311 |Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus |

| | |G40.319 |Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus |

|345.41 |intractable epilepsy cases |G40.211 |Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex |

| | | |partial seizures, intractable, with status epilepticus |

| | |G40.219 |Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex |

| | | |partial seizures, intractable, without status epilepticus |

|345.51 |intractable epilepsy cases |G40.011 |Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of |

| | | |localized onset, intractable, with status epilepticus |

| | |G40.019 |Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of |

| | | |localized onset, intractable, without status epilepticus |

| | |G40.111 |Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple |

| | | |partial seizures, intractable, with status epilepticus |

| | |G40.119 |Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple |

| | | |partial seizures, intractable, without status epilepticus |

|345.61 |intractable epilepsy cases |G40.411 |Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus |

| | |G40.419 |Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus |

|345.71 |intractable epilepsy cases |G40.111 |Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple |

| | | |partial seizures, intractable, with status epilepticus |

| | |G40.119 |Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple |

| | | |partial seizures, intractable, without status epilepticus |

|345.81 |intractable epilepsy cases |G40.803 |Other epilepsy, intractable, with status epilepticus |

| | |G40.804 |Other epilepsy, intractable, without status epilepticus |

| | |G40.89 |Other seizures |

|345.91 |intractable epilepsy cases |G40.411 |Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus |

| | |G40.419 |Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus |

| | |G40.911 |Epilepsy, unspecified, intractable, with status epilepticus |

| | |G40.919 |Epilepsy, unspecified, intractable, without status epilepticus |

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