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Radiology Coding Alert

New Codes Introduced:

Medicare Expands Coverage for PET Scans

Published on Sun Jul 01, 2001

HCFA continues to expand policies regulating Medicare reimbursement for positron emission tomography (PET) scans. Dramatic changes are effective July 1, 2001, according to Pam Kassing, director of economics and health policy for the American College of Radiology, presenting an update at the Radiology Business Managers Association (RBMA) spring educational meeting June 3-6 in Scottsdale, Ariz.

The welcome changes expand coverage for the traditionally restricted PET studies, Kassing says, and introduce new G codes to report services provided to Medicare patients. In addition, they eliminate the distinct alpha modifiers previously required on PET codes and remove onerous documentation that was required to accompany claims.

The modifications affect coding and billing for patients with Medicare coverage only. 
 
The CPT Codes used to report PET imaging studies to other insurers remain unchanged. 

Note: An explanation of the CPT codes may be found in the March 2001 issue of Radiology Coding Alert . To view this article for free this month, visit our Web site www.codinginstitute.com, and click on "HCFA Plans to Expand Coverage Areas -- Attention to Detail Increases Timely PET Imaging Pay Up."
 
New Conditions Included in PET Coverage
 
HCFA's recent announcement, published in Program Memorandum AB-01-54, had been anticipated since last December. At that time, the agency indicated it was prepared to expand coverage according to science-based data proving the effectiveness of PET for the initial diagnosis, staging and restaging of certain cancers.

Prior to July 1, Medicare coverage included one non-cancer-related use of PET (imaging of the perfusion of the heart) and restricted uses involving four cancers (initial staging of lung cancer, recurrence of colorectal cancer, staging and characterization of lymphoma, and recurrence of melanoma). With implementation of its new rules, the list of covered services is now expanded to include head and neck cancers, esophageal cancer and evaluation of refractory epileptic seizures.

The HCFA Program Memorandum also explicitly outlines several uses for related conditions that are excluded: thyroid cancer, cancer of the central nervous system including the brain, and evaluation of regional nodes in melanoma patients.
 
New Codes Describe Diagnosis, Initial Staging and Restaging Studies
 
AB-01-54 presents a comprehensive list of the G codes radiology coders are required to use when reporting PET studies. In the past, Medicare provided only one code to describe PET scanning for each distinct disease or cancer site. Now, three codes define services for each cancer  one for diagnosis, one for initial staging and one for restaging. 

Besides announcing the new codes, HCFA advised carriers about the discontinuation of G0126, G0163, G0164 and G0165, as of June 30. Also, the definition of G0125 was altered and now reads, "PET imaging, regional or whole body; single pulmonary nodule." According to Stacie L. Buck, RHIA, internal auditor for U.S. Diagnostic Inc., a corporation based in West Palm Beach, Fla., that owns and operates diagnostic imaging centers in several states, the G codes describing various myocardial perfusion studies using PET remain unchanged (G0030-G0047).
 
Some Requirements Remain the Same
 
Medicare continues to require that PET for lung cancer be performed only after evidence of an initial primary lung tumor has been found. Most often, this occurs following computed tomography (CT). "Medicare says that in order to report PET for solitary pulmonary nodules, we must be able to demonstrate that a CT or similar diagnostic study was performed and that it indicated a possibly malignant lesion," Buck explains. "It also notes that the suspected lesion cannot exceed 4 centimeters in diameter. If all these conditions are not met, the service is not billable."

Note: Other requirements were discussed in the March issue of Radiology Coding Alert and are outlined in the Medicare Coverage Issues Manual (CIM), transmittal 136.

Gone Are Unique Modifiers, Detailed Documentation
 
Prior to July 1, Medicare claims for PET studies required the use of a distinct set of alpha-character modifiers -- N (negative), E (equivocal), P (positive, not suggestive), and S (positive, suggestive). Combinations of these modifiers were appended to the procedure code to provide HCFA with information regarding the outcome of the PET scan, as well as outcomes of previous imaging studies like CT scans. Beginning in July, these requirements have been removed. "This [elimination] is wonderful news for coders, because it was such a complicated process," Buck says.

Also, local Medicare carriers may no longer require a lot of paper documentation to accompany each claim -- which may have included previous diagnostic studies (e.g., computed tomography) that revealed a possible malignant lesion indicating a need for PET imaging for further evaluation. Although some local carriers had dispensed with prerequisite documentation already, HCFA's stance now removes the requirement throughout the country, Buck explains. Instead, the Program Memorandum states that "no paper documentation needs to be submitted upfront with PET scan claims. Documentation such as physician referral and medical necessity determination are to be maintained by the provider as part of the beneficiary's medical record."

The Program Memorandum also advises that Medicare coverage is limited to PET studies conducted with the radioactive tracer substance FDG (2-{fluorine-18}-fluoro-2-dexoy-D-glucose). The only exceptions to this are the use of rubidium 82 for perfusion of the heart, myocardial viability and refractory seizure scans. Also, only studies performed with dedicated full-ring PET scanners may be billed for the new conditions approved July 1, 2001. The use of gamma camera systems with at least a 1-inch-thick crystal is still allowed for previously approved codes and conditions, pending receipt of a final ruling from HCFA. "It isn't clear why the decision about gamma cameras was made," Kassing says. However, HCFA has said that it will review its stance and announce this summer which scanners will be approved.

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