Oncology & Hematology Coding Alert

CMS has announced a national coverage determination (NCD) that will provide coverage for Fluoro-D-Glucose (FDG) Positron Emission Tomography (PET) scans for breast cancer. The NCD will take effect when it is published in the Coverage Issues Manual (CIM), the date of which is undetermined.

In the meantime, CMS has given oncology practices sufficient guidance as to how they can receive reimbursement for PET scans for breast cancer treatment. You can prepare now for the advent of new codes that will fall under the HCPCS temporary codes section and will be assigned G codes, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a consulting firm in Dallas, Ga.

According to a CMS memorandum issued Feb. 27, Medicare will cover full- and partial-ring scanners as an adjunct to standard imaging modalities for staging patients with distinct metastases such as diagnostic mammography (76090-76091, G0204, G0206 and G0236) or restaging patients with locoregional recurrence. Medicare will also cover PETs for monitoring tumor response to treatment for women with locally advanced and metastatic breast cancer. The key to coding, Parman says, is to report other diagnostic imaging procedures in the patient record to reflect the performance of other imaging procedures.

FDG PET will also be covered when oncology practices use the procedure to evaluate a patient's response to treatment. This is a reversal of the current CIM (Section 50-36), which prohibits coverage of monitoring tumor response during therapy when no change in therapy is being contemplated.

CMS reversed its policy because breast cancer typically responds quickly to therapy. Women with locally advanced tumors and metastatic breast cancer may require frequent changes in chemotherapy early in the course of treatment rather than at the end, making the PET procedure valuable in treatment management.

However, oncology practices should not use PETs indiscriminately, warns Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans. You should seek reimbursement only when it is used to evaluate the current treatment plan and if the physician is considering a change in that treatment plan, Hickey says.

The memorandum did not address using PETs for dense breast tissue. But CMS clarified that it will continue its noncoverage policy for using FDG PETs for initial breast cancer diagnosis and for initial staging of axillary lymph nodes.

CMS has determined that there was inadequate evidence to conclude that FDG PET has clinical utility in patient management when used for the initial diagnosis of breast cancer. So watch out: If you use the new codes with diagnoses other than 174.0-174.9 (Malignant neoplasm of female breast), you will receive denials because Medicare will deem the procedure medically unnecessary. Diagnosis codes such as V16.3 (Breast, family history of condition classifiable to 174) also will not be covered. Code V16.3 lacks a specific finding of breast cancer that is needed to show that the PET procedure was diagnostic.

In addition to the proper diagnosis code, medical necessity of PET scans must be determined by the provider. In some instances, results can be inaccurate, causing CMS to emphasize other diagnostic tests. For example, although FDG PET has clinical utility in patient management when used for the initial staging of axillary lymph nodes, CMS reasons, the procedure's sensitivity for nonpalpable axillary lymph nodes provides an unacceptable degree of confidence in PET for clinicians engaged in surgical planning and disease staging. Like the use of FDG PET for initial diagnosis, CMS determined that the relatively large false-negative rate (19 percent) allows for the frequent undertreatment of patients who have axillary disease. CMS feared that the false-negative results would prevent patients from undergoing axillary lymph node dissection if the treating physician relies on the PET results.