Government Relations
GR News
April 9, 2009
Billing for PET Studies in Medicare Patients, Pending Medicare Claims Guidance
On Friday April 3, 2009, the Centers for Medicare & Medicaid Services (CMS) released their final PET National Coverage Determination (NCD) that became effective on Monday April 6, 2009. CMS will not likely publish Medicare Claims Guidance until later during the month of April. Additionally, the Medicare Contractors will have 30 days to implement any new Medicare Claims Guidance, resulting in likely effective implementation dates in May/June. This means that PET providers will be following the new PET coverage rules but Medicare contractors will be using the current (old) PET claims guidance for dates of service on or after April 6, 2009.
So what does this mean for PET facilities? The SNM recommends either of two options; (1) you can bill your Medicare contractor now in accordance with the new PET coverage guidelines and using the current billing instructions (with the Q0 and V70.7 rules), expect these claims to reject initially and wait for instructions from your local Medicare contractor regarding re-processing for payment; or (2) you can hold your claims until CMS issues further guidance later this month.
Additionally, CMS published two new modifiers with effective dates of service July 2009. Providers should NOT use these two new modified before receiving the CMS instructions; these claims will be rejected because these modifiers are not yet active, nor are they in the Medicare Contractors’ systems. The SNM will have further details on these modifiers well before the July 2009 implementation date.
The SNM also would like to clarify new billing instructions for those cancers that are specifically non-covered for the initial treatment strategy evaluation. For assessing regional lymph nodes in melanoma, submit as G0219, PET imaging whole body; melanoma for non-covered indications. For diagnosis of breast cancer (evaluation of a suspicious abnormality on physical examination, mammography, or other imaging study), submit as G0252, PET imaging, full & partial-ring PET scanner only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes) Finally, for the diagnosis of prostate cancer and initial staging of newly diagnosed prostate cancer, submit as G0235 PET imaging, any site, not otherwise specified. The G0235 code should also be used for any other non-covered study, such as (1) a PET study for initial treatment strategy evaluation if the patient has previously had another study done for this purpose for the same cancer (because the new coverage policy only allows for one initial treatment strategy evaluation per patient per cancer or (2) a PET study done for "routine" surveillance of a patient with a previously treated cancer in whom there is no evidence to suggest residual or recurrent disease.
The SNM will be hosting a 90-minute webinar, "Changes to PET Coverage: Including a Review of the NOPR Sequel" on April 27, 2009 to help providers understand the final PET NCD and the new NOPR requirements.
Look for further communications from the SNM and CMS to fully understand the billing guidelines ahead for the new PET coverage under NOPR.
