Government Relations

July 20, 2009 - UPDATED August 10, 2009

CMS Issues Billing Instructions for April FDG-PET NCD Changes

Transmittal 1772, Change Request 6464, dated July 17, 2009, has been rescinded and will be replaced at a later date.

The SNM has been in communication with CMS officials regarding the billing FDG PET instructions being rescinded. We believe the rescinding is appropriate and in the best interest of the PET community. CMS is working on finalizing a simplified version of this transmittal. The SNM will post an update on the SNM coding corner web site once CMS finalizes and publishes their new instructions. In the mean time please follow the SNM guidance posted under Billing for PET Studies in Medicare Patients, Pending Medicare Claims Guidance

On July 17, 2009, CMS posted the long awaited Guidance to MACs and Billing Instructions for the April 2009 changes to the NCD on Positron Emission Tomography (FDG). Providers will have three new modifiers (in addition to the list of current modifiers) to consider when submitting claims with a date of service (DOS) April 6, 2009 for CPT codes 78811-78816. After the implementation dates of August 17 2009, or October 5 2009, based on the site of service, providers submitting claims with a DOS on or after April 6, 2009 for CPT codes 78811-78816 are now required to identify the procedure as either for initial treatment strategy or subsequent treatment strategy by appending the modifiers PI or PS, respectively.

CMS did not identify or give coding guidance for oncologic uses of Brain PET Imaging, traditionally billed using CPT code 78608. CMS officials stated they expected providers would code using CPT 78811 for covered indications for Brain PET. This CMS understanding is not consistent with longstanding AMA, SNM or ACR coding opinions (see SNM coding consensus opinion); these opinions state that providers should choose organ-specific CPT codes, if they are available, rather than generic codes. Look for more details as the medical specialty societies discuss these transmittals and their coding opinions with CMS.

Additionally, CMS identified the ICD-9 code range of 140.xx-239.xx as acceptable diagnosis codes for by-pass in their edits. The local Medicare Administrative Contractors continue to have discretion to identify additional acceptable ICD-9 codes; however, when additional local contractor codes are approved for use by a Local Coverage Determination (LCD), providers must also append the KX modifier for such claims to be paid. The KX modifier might also be used for indications not specifically listed in an LCD, under unusual or atypical circumstances where the PET facility expects to appeal for a medical review.

New Modifiers for PET Effective for Dates of Services (DOS) on or after April 6, 2009

• PI – Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing. Short descriptor: PET tumor init tx strat
• PS – Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy. Short descriptor: PET tumor subsq tx strategy
• KX – Requirements specified in the medical policy have been met.

Alternate ICD-9 diagnosis code determined by the local contractor is the only payable diagnosis submitted on the claim (and is outside the range 140.xx – 239.xx). [This modifier is used in addition to the -PI or -PS modifier.]

Since the MACs have 30 days (no sooner than August 17) to implement these changes in their systems, that means PET facilities do too. Continue to submit your claims in accordance with past instructions until your local contractor issues local instructions and implementation date. (See SNM educational news item in the related section titled Billing for PET Studies in Medicare Patients, Pending Medicare Claims Guidance.)

Details can be found in the CMS posted transmittals at:

CMS Publishes April Final PET NCD For Solid Tumors and Myeloma and Additional Manual Updates

CMS Publishes Medicare Claims Processing Instructions for PET NCD For Solid Tumors and Myeloma and Additional Manual Updates

CMS states they will post a MLN Matters Educational article. Stay tuned for more details.

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