Advanced Search

Radiology Coding Alert

Medicare Gives Green Light to Expanded PET Imaging

Published on Mon Jul 01, 2002

Much to the relief of clinicians and coders alike, CMS' recently announced new temporary codes for positron emission tomography (PET) scanning for breast cancer and myocardial viability will allow reimbursement to keep pace with current clinical practice.

Breast Cancer Codes Increase Coverage

Medicare will soon cover fluorodeoxyglucose (FDG) PET for staging and restaging for local regional recurrence or metastasis of breast cancer, says Melody W. Mulaik, MSHS, CPC, president of Coding Strategies Inc. in Atlanta.

The new codes will take effect Oct. 1, 2002, but there is more immediate relief: Medicare now recognizes FDG PET as a means to monitor treatment of a locally advanced breast cancer tumor and metastatic breast cancer when a physician is contemplating a change in therapy.

Reversing the current Coverage Issues Manual (CIM) (section 50-36), this latter modification actually reflects current clinical practice, Mulaik says. 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. The PET procedure is valuable to treatment management under these circumstances. (This is actually a part of #CAG 00094A Decision Memorandum.)

These new codes are effective for dates of service on or after Oct. 1, 2002:

G0252 PET imaging for breast cancer, 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), not covered by Medicare

G0253 PET imaging for breast cancer, full and partial-ring PET scanners only, staging/restaging of local regional recurrence or distance metastases, i.e., staging/restaging after or prior to course of treatment

G0254 PET imaging for breast cancer, full and partial-ring PET scanner only, evaluation of response to treatment, performed during course of treatment.

 

Services these codes represent will be covered only as an adjunct to other imaging modalities like diagnostic mammography. Other diagnostic imaging procedures must be documented in the patient record to reflect that they were performed, Mulaik warns. Among the diagnostic imaging procedures that will support the new PET codes are:

76090 Mammography; unilateral
76091 bilateral
G0204 Diagnostic mammography, producing direct digital image, bilateral, all views

 

 

G0206 unilateral, all views
G0236 Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, diagnostic mammography (List separately in addition to code for primary procedure).

When it announced the new codes, CMS also said its policy of noncoverage of FDG PETs for initial breast cancer diagnosis and for initial staging of axillary lymph nodes will remain unchanged. These services are described in HCPCS Code G0252, which Medicare designates as a "not covered" service.

The new codes will be paid with diagnoses in the 174.0-174.9 series (Malignant neoplasm of female breast), but not with diagnoses that lack a specific finding of breast cancer, e.g., V16.3, Family history of malignant neoplasm; breast.

 

PET Approved for Initial Myocardial Diagnoses

CMS has also loosened restrictions in the use of FDG PET for determining myocardial viability.

CMS now allows full- and partial-ring FDG PET scanning when it follows an inconclusive single photon emission computed tomography test (SPECT), e.g., 78464, Myocardial perfusion imaging; tomographic (SPECT), single study at rest or stress (exercise and/or pharmacologic), with or without quantification. The good news is that beginning Oct. 1, 2002, Medicare will cover FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascular-ization, Mulaik says. It will continue to cover FDG PET when used as a follow-up to an inconclusive SPECT. But don't assume it's a two-way street: If a patient received a FDG PET study with inconclusive results, a follow-up SPECT is not covered.

You should report two codes for these services:

G0230 PET imaging; metabolic assessment for myocardial viability following inconclusive SPECT study; full- and partial-ring PET scanners only (Should continue to be billed following an inconclusive SPECT)

78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation (Should be used for determination of myocardial viability as a primary or initial diagnostic study prior to revascularization).

Other Articles in this issue of

Radiology Coding Alert

View All