Radiology Coding Alert

Question: Does Medicare still require modifier Q0 on PET claims for cervical cancer?

Washington Subscriber

Answer: If the claim meets certain requirements, you don't need to append modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study), according to MLN Matters article MM6753.

Effective for dates of service on or after Nov. 10, 2009, Medicare has an updated national coverage determination (NCD) for FDG PET imaging for cervical cancer.

Medicare has ended the coverage with evidence development (CED) requirements for initial staging for initial treatment.

Medicare will cover one FDG PET for cervical cancer. That one exam must meet specific requirements:

• The exam must be for staging (not initial diagnosis).

• The patient must have biopsy proven cervical cancer.

• The treating physician must need the study to determine the tumor's exact location, extent, or both for the following therapeutic purposes related to initial treatment strategy:

• To determine whether the beneficiary is a candidate for an invasive diagnostic or therapeutic procedure; or

• To determine the optimal anatomic location for an invasive procedure; or

• To determine the tumor's anatomic extent when the recommended anti-tumor treatment depends on the tumor's extent.

Your claim must include all of the following for reimbursement:

• An appropriate CPT code from 78608 (Brain imaging, positron emission tomography [PET]; metabolic evaluation), 78811-78813 (Positron emission tomography [PET] imaging ...), and 78814-78816 (Positron emission tomography (PET) with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging ...)

• Modifier PI (PET Tumor initial treatment strategy)

• A cervical cancer diagnosis code (such as 180.x, Malignant neoplasm of cervix uteri).

Action step: The effective date of this policy is Nov. 10, 2009, but the implementation date is Jan. 4, 2010. Carriers won't search their files for PET cervical cancer claims for Nov. 10 to Jan. 3 dates of service, but they will adjust those claims that you bring to their attention.

Resources: To learn more, read Transmittal 110, Change Request 6753 (www.cms.hhs.gov/Transmittals/downloads/R110NCD.pdf) and MLN Matters article MM6753 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6753.pdf).