Oncology & Hematology Coding Alert

Medicare has expanded coverage for 2-[fluorine-18]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) scans allowing radiation oncologists to be reimbursed soon for diagnosing, staging and restaging of esophageal cancer and head and neck cancers. They now allow reimbursement for FDG PET scans for staging of non-small cell lung cancer and will now cover them as a diagnostic tool as well.

Radiation oncology practices that have these scans cannot, however, begin billing for this procedure until July 2001 when Medicare determines exactly how they should be coded under these new diagnoses. The American Society of Clinical Oncologys (ASCO) public policy and practices department advises that current FDG PET procedure codes are G0030-G0047. Also, HCFA has yet to assign a reimbursement amount for use of these scans on esophageal, and head and neck cancers.

According to ASCO, reimbursement is limited to selected high-performance PET scanners. Based on available studies, Medicare determined that full-ring scanners perform better than other types.

Use for FDG PET scans diagnosis is limited. They will be covered in clinical situations in which an oncology physician is trying to avoid an invasive diagnostic procedure, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a coding consulting firm in Dallas, Ga. Other diagnostic procedures, such as screenings, will not be paid for unless the patient has specific symptoms. For staging and restaging, coverage is based on two conditions:

The stage of the cancer remains in doubt after the completion of a standard diagnostic workup, including conventional imaging; and

Clinical management of the patient would differ depending on the stage of the cancer identified.

Parman says the key to showing medical necessity for diagnosis, staging and restaging is to include in the patient record specific clinical questions that the physician expects to be answered by the PET scan. For example: Is it necessary to biopsy a pulmonary nodule? The results should also be included to show the answer to the original question. A positive result will lend evidence to the need for more invasive procedures.

HCFA will keep close tabs on this new coverage, Parman warns, by reviewing records where PET scans have been used. The clinical questions must relate to the requirements described above. In a Dec. 15 decision, HCFA wrote that they plan to conduct a review within the first year following the effective date of this new policy, and will use the results to determine whether there is need for further review and to decide if revisions would be indicated.

As radiation oncology practices gear up to include these diagnoses in determining the presence and severity of these cancers, they should study reimbursement requirements for other diagnoses already covered by Medicare.

They now cover diagnosis, staging and restaging of the following types of cancers:

Non-small cell lung cancer 162.2-162.9

Colorectal cancer 153.0-153.9

Lymphoma 202.0-202.9

Melanoma 172.0-172.9

Clues in Current Covered Procedures

Current PET scan procedures can offer hints as to Medicares documentation requirements that will be coming out in July. Those using FDG for staging non-small cell lung carcinoma (NSCLC) are covered only when used for the initial staging of suspected metastatic NSCLC in thoracic lymph nodes in patients who have a confirmed primary lung tumor, but whose extent of disease has not yet been established.

Multiple staging procedures using PET scans are considered monitoring the progress of the disease, rather than staging, and are not paid for at this time. Initial staging of NSCLC with a PET scan using FDG must meet the following conditions:

Evidence that a primary cancerous lung tumor has been confirmed. This should include, but is not limited to, a surgical pathology report that documents the presence of an NSCLC.

Evidence of performance of both a concurrent tho racic (CT) which is necessary for anatomic information and of any lymph node biopsy to finalize whether the patient will be a surgical candidate.

While these requirements establish when a PET scan is reimbursed, it may prevent the radiation oncologist from billing other procedures, such as a lung biopsy, Parman says.

For example, a lymph node biopsy is not covered in the case of a negative CT and negative PET, when the patient is considered a surgical candidate and presumed to be absent of metastatic NSCLS. For the biopsy to be a paid service, a medical review to support necessity of a biopsy is required when it falls outside a carriers requirements. A lymph node biopsy is reimbursable in all other cases, including a positive CT and positive PET, negative CT and positive PET, and positive CT and negative PET.

Code G0126 (PET lung imaging of solitary pulmonary nodules using 2-[fluorine-18]-fluoro-2-deoxy-d-glucose [FDG], following CT [71250/71260 or 71270]; initial staging of pathologically diagnosed non-small cell lung cancer) should be used for PET lung imaging of solitary pulmonary nodules, and 71250 (computerized axial tomography, thorax without contrast material) and 71260(... with contrast material[s]) or 71270 (... without contrast material, followed by contrast material[s] and further sections) for the CT. Documentation should indicate that the PET followed the CT for initial staging of pathologically diagnosed non-small cell lung cancer.

Using Special Modifiers

Special modifiers must be used to indicate the results of the PET and the previous test. Code G0126 should have two of the following modifiers to indicate the results of both imaging procedures: N (negative), E (equivocal), P (positive, not suggestive), and S (positive, suggestive). P indicates positive, but is not suggestive of extensive ischemia or not suggestive of malignant single pulmonary nodule. S indicates positive and is suggestive of extensive ischemia or malignant single pulmonary nodule.

The P modifier is used to indicate the results of the PET scan, while the S modifier indicates the results of the prior test. Claims submitted without the two modifiers are normally denied.

The requirements for covering PET scans for staging non-small cell lung cancer highlight the difficulties
surrounding getting paid for the procedure, Parman says. They underline how Medicare emphasizes using other
imaging procedures before using a PET scan. They want you to show that you have used other imaging procedures and that by using these scans you can determine the best course of treatment, especially if you can avoid unnecessary costs and unneeded invasive procedures.