Radiology Coding Alert

NOPR stats seal the deal for expanded tumor imaging coverage.

If youve been reporting to the National Oncologic PET Registry (NOPR), congratulations -- your hard work has paid off.

The lowdown: CMS is crediting data submitted to NOPR for a recent expansion of PET coverage for initial anti-tumor treatment strategy.

This expansion in coverage for PET scans shows that the Coverage with Evidence Development program is a success, according to CMS acting administrator CharleneFrizzera in an April 6 release. CED allowed us to cover an emerging technology, learn more about its usage in clinical practice, and adjust our coverage policies accordingly.

For a great many patients, who would otherwise have to pay out-of-pocket for their PET scans, this CMS decision will save thousands of dollars. It will also allow more providers to offer this lifesaving care to our nations seniors, stated R. Edward Coleman, MD, in an ACR press release. Coleman is a member of the NOPR working group, former chair of the ACR Nuclear Medicine Guidelines and Standards Committee, and chief of Nuclear Medicine at Duke University Hospital.

Dont Miss the 1-Scan Rule

Be sure you catch two changes in the policy:

1. Framework: Instead of having categories for diagnosis, staging, restaging, and monitoring response to treatment, CMS now has a two-part framework:

" Initial Anti-Tumor Treatment Strategy, formerly diagnosis and staging

" Subsequent Anti-Tumor Treatment Strategy, formerly restaging and monitoring response to treatment.

2. Coverage: CMS will cover one FDG PET study for beneficiaries with solid tumors that are either:

" Biopsy proven OR

" Strongly suspected based on other diagnostic testing.

For coverage, the treating physician must determine that the patient needs the FDG

PET study for one of these reasons:

" To determine whether the beneficiary is an appropriate candidate for an invasive procedure (diagnostic or therapeutic)

" To determine an invasive procedures optimal anatomic location

" To determine the tumors anatomic extent when the recommended anti-tumor treatment depends on this extent.

Exceptions: PET isnt covered for all solid tumors. See below for the coverage rundown:

Beware Strings Attached for Initial/Subsequent

Initial and subsequent treatment strategy scans are covered for the following solid tumor-type cancers: colorectal, esophageal, head and neck (not thyroid or CNS),lymphoma, non-small cell lung, ovary, and myeloma.

For the following types, an initial scan is covered, but subsequent treatment scans still fall under CED/NOPR: brain, small cell lung, soft tissue sarcoma, pancreas, and testes.

But a few cancer types have special coverage rules, as shown in the chart on the next page.

All other solid tumors, CMS covers for initial treatment scans but fall under CED/NOPR for subsequent treatment scans.

Dont give up: SNM plans on continuing to partner with concerned organizations to seek coverage for other cancer types for which PET has a proven medical and therapeutic value, according to Robert W. Atcher, PhD, MBA, president of SNM and University of New Mexico/Los Alamos National Laboratory professor of pharmacy, in a press release.

SNM offers the following coding advice for the noncovered services:

" For assessing regional lymph nodes in melanoma,report G0219 (PET imaging whole body; melanoma for noncovered indications).

" For breast cancer diagnosis, report G0252 (PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer [e.g., initial staging of axillary lymph nodes]).

" For prostate cancer diagnosis and initial staging report G0235 (PET imaging, any site, not otherwise specified), which is also appropriate for other non-covered studies.

You should use the G codes on Medicare claims if you give the patient an ABN and he selects option 1 (I want the [service] listed above & I also want Medicare billed for an official decision). Medicare will not pay for these non-covered scans, but once Medicare denies the claim, the patient will be able to submit it to his secondary insurance, if any, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

If the patient selects option 2 (I want the [service] listed above, but do not bill Medicare), you wont submit a claim to Medicare, so the code assignment isnt an issue, Miller says.

Decide Whether to Hold Your Claims

CMSs new PET NCD became effective April 6, but experts predict an implementation date later in the spring or summer, allowing CMS to publish guidance and contractors to update their systems.

SNM suggests that until contractors get up to speed,you have two reporting options:

1. Bill Medicare for the newly covered PET scans you perform with modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) and V70.7 (Examination of participant in clinical trial) along with the appropriate principal diagnosis code, but expect rejections and stay alert for instructions on reprocessing claims OR

2. Hold your claims for a few weeks until CMS issues guidance.

Resource: You can find this information in the April 9 article Billing for PET Studies in Medicare Patients,Pending Medicare Claims Guidance at (http://interactive.snm.org/index.cfm?PageID=8612).

Check these out, too: You can find the decision memo on the CMS Web site at www.cms.hhs.gov/mcd/viewnca.asp?nca_id=218&basket=.

Search for NOPR information online at www.cancerpetregistry.org/index.htm. NOPR also offers a coverage chart with ICD-9 codes (http://interactive.snm.org/docs/Appendix_III_NOPR_Table_4-4-09_FINAL.pdf).

But remember that your local carrier may post its own list of which ICD-9 codes it covers.