FDG PET for Solid Tumors NCD Removes CED Requirement
The Centers for Medicare & Medicaid Services (CMS) has removed the coverage of evidence (CED) requirement in the national coverage determination (NCD) for fluorodeoxyglucose (FDG) positron emission tomography (PET) for solid tumors, effective June 11, 2013.
CMS will cover three FDG PET scans (without the CED requirement) when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same cancer diagnosis. Coverage beyond three scans for the same cancer diagnosis is up to the discretion of your local Medicare administrative contractor (MAC).
What this means for coders is that you no longer need to use modifiers Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study and Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study, along with condition code 30 Qualifying clinical trial or ICD-9-CM code V70.7 Examination of participant in clinical research on claims for these services.
Continue to report FDG PET or PET/computed tomography (CT) scans with CPT® codes 78608, 78811, 78812, 78813, 78814, 78815, 78816, with either modifier PI PET or PET/CT to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing for an initial scan or modifier PS PET or PET/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 for subsequent scans.
Report also the associated supply with HCPCS Level II code A9552 Fluorodeoxyglucose f-10 FDG, diagnostic, per study dose, up to 45 millicuries and the same cancer diagnosis code.
Each different cancer diagnosis is also allowed an initial treatment strategy (modifier PI) scan and three subsequent treatment strategy scans (modifier PS).
For additional scans for the same cancer diagnosis, append modifier KX Requirements specified in the medical policy have been met.
Remember: To use modifier KX, additional documentation must be available to support the medical necessity of the service being performed in accordance with medical policy.
Source: MLN Matters® Number: MM8468