Medicare Compliance & Reimbursement

CPT descriptor changes pave the way for coverage

With all the bad news that's hit imaging lately, you're overdue for a break.

So it's good news that CPT 2008 greatly increases the number of patients for whom you can bill FDG Positron Electron Tomography (PET) codes 78811-78816. January's CPT update deletes the phrase "tumor imaging" from the descriptors for these codes.

That change opens the door for the Centers for Medicare & Medicaid Services (CMS) to start covering FDG-PET when your physician scans for infections and inflammations, as well as tumors.

"Just because the word tumor is removed doesn't mean CMS is going to change coverage," cautions Denise Merlino, president of Merlino Healthcare Consulting Corp. in Stoneham, MA. CPT 2008 removed the word "in anticipation of potential changes in coverage, or for private payors who might choose to cover other procedures," she notes.

Abass Alavi, a radiology professor at the University of Pennsylvania, wrote CMS in May to request an expansion in coverage for FDG-PET. Alavi originally requested coverage for all infection and inflammation, but after meeting with CMS' Coverage and Analysis Group (CAG), he narrowed the request to three conditions: chronic osteomyelitis, infection associated with hip arthroplasty, and "fever of unknown origin."

"FDG-PET's diagnostic efficacy is particularly well established" for these three conditions, he noted in his letter to CMS.

In response to his request, CMS opened a National Coverage Determination (NCD) review and will issue a decision early next year.

The Society for Nuclear Medicine (SNM), the American College of Radiology (ACR) and the Academy of Molecular Imaging (AMI) have all written to CMS to support covering FDG-PET for infection and inflammation, either as an alternative to conventional imaging, or when conventional imaging is "indeterminate."

In 2005, physicians performed roughly one million PET studies for tumors and approximately 100,000 non-PET nuclear medicine studies for inflammatory processes. When SNM and ACR requested the changes to 78811-78816, they predicted around 50,000 of those 100,000 yearly scans would involve PET instead.

Bottom line: You soon could have a new use for your PET scanner for thousands of patients.