Radiology Coding Alert

PET Scan pay hinges on diagnosis coding more than most procedures.

When it comes to coverage determinations, Medicare is extremely particular about what diagnoses will qualify for payment of positron emission tomography (PET) scans. As this equipment is costly and challenging to operate within an imaging facility, the relative value units (RVU) for these procedures are understandably quite high.

In order to counter for unnecessary use of PET scans, Medicare has put together a strict set of eligibility requirements which the patient must meet in order to be considered for this procedure.

Read on for tips and practical advice to help code PET scans efficiently and effectively.

Memorize These Medicare Policies

"Medicare sets forth very stringent guidelines concerning PET scans," says Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York. "Coders should utilize the National Coverage Determinations [NCDs], as well as the supplemental Medicare Learning Network articles published by The Centers for Medicare and Medicaid Services (CMS) to determine whether a particular circumstance or diagnosis is covered," Corney relays.

Medicare's policies dictating whether or not a patient meets the necessary requirements for a PET scan generally comes down to a matter of diagnosis. Medicare states that it will only cover PET scans when used to determine the location and/or extent of a tumor. Additionally, the treating physician must order the PET scan for the following therapeutic services:

• To determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure;
• To determine the optimal anatomic location for an invasive procedure; or
• To determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.

Specifically, the Centers for Medicaid and Medicare Services states that these guidelines are exclusively applicable to "beneficiaries who have cancers that are biopsy-proven or strongly suspected based on other diagnostic testing."

You also want to be aware of the circumstances in which a Medicare will not cover a PET scan. There are particular circumstances in which a patient still may not be covered despite the fact that they have a biopsy-proven malignancy. You will want to keep these three nationally noncovered indications in mind when coding PET scans:

• CMS doesn't cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate.
• CMS doesn't cover fluorodeoxyglucose (FDG) PET imaging for initial anti-tumor treatment strategy for the evaluation of regional lymph nodes in melanoma.
• CMS doesn't cover FDG PET imaging for the diagnosis of cervical cancer related to initial anti-tumor treatment strategy.

Note These Key Points

Medicare will pay for a diagnosis of melanoma as long as the physician does not order the PET scan for an evaluation of the regional lymph nodes. A cervical cancer diagnosis will also be paid if the physician performs the PET scan for detection of pre-treatment metastasis in newly diagnosed individuals following conventional imaging.

Additionally, Medicare will not cover a PET scan that a physician orders for any form of infection and/or inflammation. Specifically, Medicare states that they will not cover PET scans for chronic osteomyelitis, infection of hip arthroplasty, and/or fever of unknown origin. In fact, Medicare goes on to explain that the performing of a PET Scan is "not reasonable and necessary to diagnose or treat an illness or injury or to improve the functioning of a malformed body member and, therefore, is not covered" under section 1862 (a)(1) of the Social Security Act.

CMS Covers Breast Cancer, with Exceptions

Most coders who work on PET scan claims will undoubtedly come across numerous breast cancer diagnoses on a routine basis. However, it's important that both providers and coders alike are aware of when a breast cancer diagnosis is not enough to justify ordering a PET scan.

For example, CMS will cover a PET scan for the "initial anti-tumor treatment strategy for male and female breast cancer only when used in staging distant metastasis." In other words, the breast cancer has to have metastasized in order for the PET scan to be paid. However, if the physician performs a PET scan for an initial diagnosis of breast cancer (male or female) and/or for staging of the axillary lymph nodes, Medicare will not cover the procedure.

Know Initial vs. Subsequent Treatment Strategies

Medicare sets guidelines limiting the allotment of PET scans a patient may receive in a given year. "The degree of coverage is determined by treatment strategy," states Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. For the initial treatment strategy (formerly diagnosis and initial staging), Medicare nationally covers one PET scan with additional scans covered at the discretion of each local Medicare Administrative Contractor (MAC).

"For the subsequent treatment strategy, which includes treatment monitoring, restaging, and detection of suspected recurrence, three PET scans are nationally covered by Medicare with additional scans covered at the discretion of each local MAC," Della Vella explains.