CMS Clarifies Billing Instructions for April FDG-PET NCD Changes

October 21, 2009

CMS Clarifies Billing Instructions for April FDG-PET NCD Changes

CMS Transmittal’s 1833 & 108, Change Request 6632, which rescinds Transmittals 1817 and 106, dated October 16, 2009.

The effective date has been changed to April 3, 2009 and the implementation date has been changed to October 30, 2009. Business Requirements (BR) 6632.6.1 and 6632.6.2 have been revised to clarify that they are subsets of BR 6632.6 and are specific to CED. All other information remains the same.

On September 18, 2009, CMS released to the Medicare Administrative Contractors (MACs) the long awaited and reissued Guidance and Billing Instructions for the April 2009 changes to the National Coverage Determination (NCD) on Positron Emission Tomography (FDG). Providers will have two 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 78608, 78811-78816 for oncologic procedures. Available on or after the implementation date of October 30, 2009, providers submitting claims with a DOS on or after April 3, 2009 for CPT codes 78608, 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.

The SNM applauds CMS for a greatly simplified new set of billing instructions for FDG PET procedures. CMS removed the previously identified ICD-9 range of codes allowing discretion at the local level with the Medicare Contractors. CMS did identify the combination of PI and ICD-9 codes that are newly non-covered 185 for adenocarcinoma of prostate. Providers participating in the national oncologic PET registry (NOPR) for those procedures which continue to be covered only under coverage with evidence development (CED) continue to use the Q0 (zero) modifier and/or V70.7 in the second diagnosis position with condition code 30 in addition to using one of the two new modifiers below.

New Modifiers for PET Effective for Dates of Services (DOS) on or after April 3, 2009 Implemented on or after October 30, 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

Since the MACs have until October 19, 2009 to implement these changes in their systems which means PET facilities will likely have similar transition time. 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 below titled "Billing for PET Studies in Medicare Patients, Pending Medicare Claims Guidance".)

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