| SPN and MPN PET Medicare Coverage |
Created: June 22, 2009
Revised: January 25, 2010 |
| Question |
| We are confused about the Medicare PET coverage for lung masses, solitary pulmonary nodules and multiple pulmonary nodules. Can you please clarify? In the past we were billing with diagnosis codes 518.89 or 793.1 prior to biopsy when a biopsy was not available or medically feasible. Can you tell us which ICD 9 indications the Medicare contractors will accept as payable? |
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| Answer |
Deciding whether or not to do a PET scan and whether or not it is covered requires medical judgment, as well as compliance judgment. Where PET fits into the continuum in the evaluation of patients with lung nodules depends on many factors including the full clinical history, risk factors for lung cancer, history of prior cancers, the CT appearance of nodule(s), etc. Thus, the answer rests on the specific clinical question being posed by the referring MD. Moreover, the question should be well thought out before ordering an expensive diagnostic test.
To address the questions, we will give a few examples, but these are by no means all of the possibilities. Each of these examples are included under the current Medicare coverage for "initial treatment strategy".
As a general rule, it is usually preferable to get a tissue diagnosis before launching a complex imaging evaluation of a suspected cancer anywhere in the body. This is not always possible, however, and not always the best first step.
In the case of a single nodule or mass thought highly likely to be a primary lung cancer, PET is often ordered before biopsy, less as a test to diagnose cancer, but rather to stage the cancer. If PET demonstrates other lesions (e.g., supraclavicular or mediastinal nodes), it may be far easier to biopsy these than the index lesion in the lung.
In the case of an indeterminate solitary pulmonary nodule, PET is done for "diagnosis" (to determine whether the lesion is more likely benign or malignant). If PET is negative, the patient typically does not undergo biopsy. In other words, PET helps in this situation to avoid an invasive diagnostic procedure. The situation is similar with an indeterminate biopsy; if PET is negative, the patient is typically followed and avoids an even more invasive diagnostic procedure (resection by VATS or thoracotomy).
The situation with multiple pulmonary nodules also involves several scenarios.
If one or more of the nodules appear spiculated and the patient is a smoker, such that multifocal adenocarcinoma of the lung is the most likely diagnosis, we would view this as an instance of "Lung Cancer: Diagnosis", which is definitely a Medicare-covered indication. Depending on which ICD-9 codes your carrier accepts for a case like this as indicating medical necessity, you may need to be prepared to appeal for payment. Thus, extra care in documentation of medical necessity in the PET report is advised.
If the multiple nodules appear round and smooth and there is significant clinical concern for metastatic disease to the lungs from an unknown primary tumor, PET previously would have had to be performed under NOPR as "Diagnosis: Unknown Primary". This is now a Medicare-covered indication. The same proviso as above regarding ICD-9 codes to document medical necessity applies. We repeat, extra care to document medical necessity in the PET report is advised.
If the patient has a previously treated cancer and now has new pulmonary nodules, PET may be appropriate to evaluate for suspected recurrence of that cancer. This "subsequent treatment strategy" use of PET may be covered or may have to be done under NOPR depending on the type of cancer for which the patient was previously treated. |
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Each Medicare Administrative Contractor (MAC) develops its own list of covered ICD-9 codes based on the current National Coverage Determination (NCD) for PET. Most Medicare contractors have developed these lists of ICD-9 codes and frequency limits to support medical necessity based on their interpretation of the current NCD. There is considerable, continuing dialog between providers, medical specialties and contractors regarding some LCDs in which the diagnosis codes 518.89 or 793 were not included as covered ICD 9 codes. The SNM does not believe that absence of these codes is a guaranteed final decision of denial by the local Medicare Administrative Contractor. We believe that providers should continue to code appropriately following ICD 9 coding guidelines and if you are in one of those States that have omitted these ICD 9 codes you should expect an initial denial of the claim. The provider should be prepared to submit an appeal to the Medicare contractor with appropriate supporting documentation. As with any denial, providers may always appeal initial MAC decisions. Should the appeal be denied and you continue to believe it was denied without merit you should ask for a review of the claim and the situation with the MAC Medical Director.
Please visit here to see the final CMS PET NCD.
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| Disclaimer
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| The opinions referenced are those of the members of the SNM Coding and Reimbursement Committee and their consultants based on their coding experience. They are based on the commonly used codes in Nuclear Medicine, which are not all inclusive. Always check with your local insurance carriers as policies vary by region. The final decision for the coding of a procedure must be made by the physician considering regulations of insurance carriers and any local, state or federal laws that apply to the physicians practice. The SNM and its representatives disclaim any liability arising from the use of these opinions.
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