Oncology & Hematology Coding Alert

Medicare has issued 21 temporary codes (effective July 1, 2001) for reporting positron emission tomography (PET) scan procedures used to diagnose, stage and restage esophageal, head and neck, lung and colorectal cancers, lymphoma and melanoma. The new G codes replace G0126 (PET lung imaging of solitary pulmonary nodules, using -2-[fluorine-18]-flouro-2-deoxy-d-glucose [FDG] following CT [71250/71260 or 71270]), G0163 (positron emission tomography [PET], whole body, for recurrence of colorectal metastatic cancer), G0164 (positron emission tomography [PET], whole body, for staging and characterization of lymphoma) and G0165 (positron emission tomography [PET], whole body, for recurrence of melanoma or melanoma metastatic cancer).
 
The G codes listed on page 66 were assigned following Medicare's announcement earlier this year that it would expand coverage for PET scans. Medicare now  allows payment for FDG PET scans for staging of non-small-cell lung cancer. The most significant change allows for the use of FDG PET scans when diagnosing malignancy. Previously, Medicare reimbursed for the use of less expensive diagnostic procedures, such as computed tomography (CT) scans, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a coding consulting firm that works extensively with radiation oncology practices in Dallas, Ga.

 
PET scans performed after July 1, 2001, should be reported using the new codes. However, Medicare carriers have yet to update their local medical review policies (LMRPs), which determine medical necessity, so radiation oncology practices that bill for these newly covered procedures face uncertain reimbursement, Parman says.
 
The release of LMRPs could be as late as the end of this year for some carriers, predicts Denise Butler, CPC, team leader and coder for Medical Management Professionals in Knoxville, Tenn.
 
Parman predicts that many practices face denials because of the absence of LMRPs and the requirement to use the new codes for diagnosis of malignancy despite no medical-necessity guidelines. However, Medicare offers insight into how PET procedures will be approved for reimbursement now.

 
The inclusion of PET scans for diagnosing malignancy is the most radical change. PET scans offer the latest technology in detecting certain types of cancers, but the procedure is expensive. To avoid overuse of this procedure, Medicare and commercial payers have previously limited its use to staging and restaging cancers. While the coverage now includes diagnostic use, the door has been opened only slightly, Parman says.
 
Radiation oncology practices should be conservative when billing for diagnostic PET scans. According to Medicare's policies for diagnostic coverage, a PET scan is covered only in clinical situations where the results of the procedure would help physicians avoid invasive diagnostic procedures. These would include using PET results to avoid invasive lung biopsy (32405 and 32095-32100) or if results would help determine an optimal anatomic location to perform an invasive diagnostic procedure. PET is not covered for screening evaluations, which CMS defines as the testing of patients without signs and symptoms of disease.
 
LMRPs will determine the documentation needed to get diagnostic use of PET scans paid, but there is a strong likelihood that radiation oncology practices will have to document specific symptoms that lead physicians to suspect a certain cancer. Code G0210, for example, may not be paid unless it is accompanied by documentation that shows the patient has symptoms of non-small-cell lung cancer, such as recurring bronchitis (491.0-491.9) or pneumonia (480.0-486) and blood in the sputum. Also, to code G0210, the PET scan must be performed before any other diagnostic tool. If the patient has already had a positive CT scan, or a brush or needle biopsy, the code for diagnosing malignancy would not be used. Instead, G0211 for initial staging should be reported. Other diagnostic procedures include imaging tests such as x-rays (71010-71035), computed tomography (CT) scan (71275), magnetic resonance imaging (MRI) (71550-71552), sputum cytology (89350) and blood tests.
 
Parman believes that diagnostic-related codes will be used sparingly because it is more likely that patient-reported symptoms will prompt other types of diagnostic tests. Loss of weight and appetite, for instance, is a symptom of lung cancer, but not one that would immediately prompt a PET scan. Odds are in favor of physicians detecting cancer in other ways that would preclude codes such as G0210.

Staging and Restaging
 
 
Conservatism is also prudent when coding for staging and restaging cancers. Radiation oncology practices must be careful to stay within the strict definition of "staging" and "restaging." For example, multiple PET scans may be considered monitoring the progress of the disease, rather than staging, and would likely fall outside the coverage guidelines.
 
Staging and restaging via PET scans are covered in either or both of the following:
 

The stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (CT, MRI or ultrasound [US]).
 

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

 
Using G0211 as an example again, coding of the initial staging of non-small-cell lung cancer should mean that evidence of a primary cancerous lung tumor -- such as a surgical pathology report that documents the presence of the disease -- is included in the patient medical record. The patient chart may also contain evidence of both the performance of a concurrent thoracic CT, which would be necessary for anatomic information, and performance of any lymph-node biopsy to finalize whether the patient will be a surgical candidate.
 
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 through the administration of a PET scan,  Parman says. Questions may include: Is it necessary to biopsy this pulmonary nodule? The PET scan results should also be included to show the answer to the original question. A positive result will support the need for more invasive procedures.
 
Parman warns that CMS will keep close tabs on this new coverage by reviewing records where FDG PET scans have been used. The clinical questions must relate to the requirements described above. In a Dec. 15, 2001, decision, CMS wrote: "[CMS] plans to conduct a review within the first year following the effective date of this new coverage, and will use the results to determine whether there is any need for further review and to decide whether revisions to the coverage policy would be indicated."
 
No Need for Modifiers

 
In the past, special modifiers had to be used to indicate the results of PET scans and the previous test results that created a need for a PET service. For example, G0126 used to require two of the following modifiers to indicate the results of both imaging procedures: N (negative), E (equivocal), P (positive) and S (positive and suggestive of extensive ischemia or malignant single pulmonary nodule).  
 
Parman says these modifiers are no longer needed and Medicare will accept these codes despite their absence.