New Coding and Coverage for PET Scans

Vol. 11 •Issue 18 • Page 8
New Coding and Coverage for PET Scans

Back in April, the Centers for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration) published instructions to fiscal intermediaries and carriers about expanded Medicare coverage for positron emission tomography (PET) scans. The coverage applies to claims with dates of service on or after July 1, 2001. According to transmittal AB-01-54 from CMS, PET scan coverage now includes the following:
• Diagnosis, initial staging and restaging of non-small cell lung cancer
• Diagnosis, staging and restaging of PET for colorectal cancer
• Initial staging and restaging of Hodgkin’s and non-Hodgkin’s diseases
• Diagnosis, initial staging and restaging of melanoma and esophageal cancer (no coverage for evaluation of regional nodes)
• Head and neck cancers (no coverage for central nervous system or thyroid cancers)
• Presurgical evaluation for patients with refractory seizures

Coverage also will be available when a PET scan is done following an inconclusive single photon emission computed tomography (SPECT) for myocardial viability. If a patient has received a SPECT and the results are inconclusive, the physician may order a PET scan (with the proper documentation).

Also beginning July 1, procedures performed with dedicated full-ring scanners will be covered. For indications covered before this date, all PET scanners approved or cleared for marketing by the FDA remain covered.

Limitations Defined

CMS defined diagnosis, staging and/or restaging, and monitoring as they apply to PET (excluding Rubidium 82 for perfusion of the heart, myocardial viability and refractory seizures) and outlined the limitations for staging and restaging. PET is covered in either or both of the following circumstances:
• The stage of the cancer remains in doubt after completion of a standard diagnostic work-up, including conventional imaging (computed tomography, magnetic resonance imaging or ultrasound).
• The patient’s clinical management would differ depending on the cancer stage identified. PET will be covered for restaging after the completion of treatment to detect residual disease or suspected recurrence or to determine the extent of a known recurrence. Use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when the results are insufficient for clinical management.

PET is not covered for other diagnostic uses, screening tests or for monitoring tumor response during planned therapy (i.e., when no change in therapy is being contemplated). In addition, Medicare contractors will, when necessary, develop frequency limitations on any or all covered PET scan services if no national limits exist.

Billing Requirements

Providers will no longer be required to submit PET scan modifiers N, E, P and S up-front. They also do not have to submit up-front paper documentation, although it must be kept in the medical record and available to the payer upon request.

It is the ordering physician’s responsibility to certify the medical necessity of the PET study according to the patient’s condition. The physician must have documentation in the beneficiary’s medical record to support the referral supplied to the PET scan provider. The documentation also must prove that the procedure involved only FDA-approved drugs and devices and did not involve investigational drugs or procedures.

Claims for PET scan services billed on the HCFA-1500 form or its electronic equivalent must include the appropriate HCPCS and diagnosis codes. The type of service (TOS) for the new PET scan procedure codes is 4 (diagnostic radiology).

Claims billed on the UB-92 claim form or its electronic equivalent must include the appropriate diagnosis HCPCS “G” codes to indicate the conditions under which a PET scan was done. These codes represent the technical component costs associated with these procedures when furnished to hospital outpatients and are paid under the outpatient prospective payment system. Bill these codes under revenue code 404 (PET scan).

CMS also advised payers to remind providers of the following in relation to the expanded coverage:
• PET scanning facilities must keep patient record information on file for each Medicare patient for whom such a PET scan claim is made.
• The medical records can be used in any post-payment review and must include the information necessary to substantiate the need for the PET scan.
• The medical records must include standard information (e.g., age, sex and height) along with any annotations regarding body size or type that indicate a need for a PET scan to determine the patient’s condition.

In addition to the above transmittal, more information on coverage of PET scans may be found in section 50-36 of the Medicare Coverage Issues Manual (www. pubforms/progman.htm). *

Jeff Majchrzak is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.

New Level II Codes for PET Scans

The following codes should be used for claims with dates of service on or after July 1, 2001. See the “notes” at the end of the box for other code revisions.

Level II Codes and Descriptions
G0210 PET imaging whole body; diagnosis; lung cancer, non-small cell
G0211 PET imaging initial staging; lung cancer;
non-small cell (replaces G0126)
G0212 PET imaging whole body; restaging; lung cancer; non-small cell
G0213 diagnosis; colorectal cancer
G0214 initial staging; colorectal cancer
G0215 restaging; colorectal cancer
(replaces G0163)
G0216 diagnosis; melanoma
G0217 initial staging; melanoma
G0218 restaging; melanoma (replaces G0165)
G0219 melanoma for non-covered indications
G0220 diagnosis; lymphoma
G0221 initial staging; lymphoma
(replaces G0164)
G0222 restaging; lymphoma (replaces G0164)
G0223 diagnosis; head and neck cancer; excluding thyroid and CNS cancers
G0224 PET imaging whole body or regional;
initial staging; head and neck cancer; excluding thyroid and CNS cancers
G0225 restaging; head and neck cancer, excluding thyroid and CNS cancers
G0226 PET imaging whole body; diagnosis; esophageal cancer
G0227 initial staging; esophageal cancer
G0228 restaging; esophageal cancer
G0229 PET imaging; metabolic brain imaging for presurgical evaluation of refractory seizures
G0230 metabolic assessment for myocardial viability following inconclusive SPECT study
(1) The narrative for code G0125 has changed to “PET imaging regional or whole body; single pulmonary nodule.”
(2) Codes G0126, G0163, G0164 and G0165 have been discontinued as of June 30, 2001.

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