Oncology Coding: Update Your PET Claims With This New Guidance

February 7, 2010

Here are the requirements the exam must meet, according to Medicare.

If your PET claim meets certain requirements, you don’t need to append modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study), according to MLN Matters article MM6753.

Effective for dates of service on or after Nov. 10, 2009, Medicare has an updated national coverage determination (NCD) for cervical cancer FDG PET imaging. Medicare has ended the coverage with evidence development (CED) requirements for initial staging of initial treatment.

Medicare will cover one FDG PET for cervical cancer. That one exam must meet specific requirements:

The exam must be for staging (not initial diagnosis).
The patient must have biopsy proven cervical cancer.
The treating physician must need the study to determine the tumor’s location, extent, or both for one of the following therapeutic purposes related to initial treatment strategy:
To determine whether the beneficiary is a candidate for an invasive diagnostic or therapeutic procedure
To determine the optimal anatomic location for an invasive procedure
To determine the tumor’s anatomic extent when the recommended anti-tumor treatment depends on that information.

Codes: Your claim must include all of the following for reimbursement:

An appropriate CPT code from 78608 (Brain imaging, positron emission tomography [PET]; metabolic evaluation), 78811-78813 (Positron emission tomography [PET] imaging …), or 78814-78816 (Positron emission tomography (PET) with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging …)
Modifier PI (PET Tumor initial treatment strategy)
A cervical cancer diagnosis code (such as 180.x, Malignant neoplasm of cervix uteri).

Action step: The effective date of this policy is Nov. 10, 2009, but the implementation date is Jan. 4, 2010. Carriers won’t search their files for PET cervical cancer claims for Nov. 10 to Jan. 3 dates of service, but they will adjust those claims that you bring to their attention.

Resources: To learn more, check out Transmittal 110, Change Request 6753.

@ Oncology Coding Alert

Want to become an oncology coding expert? Attend this ENCORE presentation of the 2010 Oncology Coding Update, presented by Brenda Chidester.

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