New FDG PET Reporting Requirements
The Centers for Medicare & Medicaid Services (CMS) is revising Section 220.6 of the National Coverage Determinaton (NCD) Manual to reflect a new coverage framework for the use of F-18 flouro-D-glucose positron emission tomography (FDG PET) in determining initial and subsequent onocologic treatment strategies, as outlined in the NCD (CAG-00181R).
CMS is adopting a coverage framework that replaces the four-part diagnosis, staging, restaging, and monitoring response to treatment categories with a two-part framework that differentiates FDG PET imaging used to inform the initial antitumor treatment strategy from other uses related to guiding subsequent antitumor treatment strategies after the completion of initial treatment.
Beginning Oct. 5, all PET FDG oncologic-related claims for dates of service on or after April 6, MUST include one of the following two new modifiers for the claim to be processed correctly:
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
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 the PET study is needed to inform subsequent anti-tumor strategy
Claims for FDG PET imaging for oncologic indications for initial treatment strategy containing modifier PI are covered by Medicare only one time per cancer indication.
For PET FDG oncologic claims where an alternate ICD-9 diagnosis code determined by the local contractor is the only payable diagnosis submitted on the claim (i.e., outside the 140.xx -239.xx range), append procedure code modifier -KX (Requirements specified in the medical policy have been met) in addition to either the PI or PS modifier. For PET FDG oncologic-related claims for dates of service on or after April 6, CMS has designated ICD-9 cancer diagnosis codes 140.xx-239.xx as appropriate, as well as any alternate ICD-9 diagnosis code the local contractor deems appropriate.
For more information, please refer to CMS Transmittal 104, change request 6464, issued July 17.
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