Neurology & Pain Management Coding Alert

Although physicians wishing to bill Medicare for positron emission tomography (PET) scans face a web of ever-changing and seemingly ever-multiplying guidelines, the restrictions may benefit neurologists (in a sense) because they limit PET scan billing to one indication and a single applicable code. Get to Know Your PET As defined by Medicare decision memorandum CAG-00065N, which anticipates national Medicare policy for PET scans, positron emission tomography "is a noninvasive diagnostic imaging procedure that assesses the level of metabolic activity and perfusion in various organ systems of the human body." For example, a physician can use PET scans of the brain to evaluate patients who have memory disorders of an undetermined cause, who have suspected or proved brain tumors, or (as explained below) who have seizure disorders that are not responsive to therapy and are therefore candidates for surgery. You'll Report G0229 ...and Like It! Since 1995, when CMS (then HCFA) issued its first coverage decision on the technology, Medicare has covered PET scans for more and more indications, including various cancers (lung, skin, breast, etc.), lipomas and metastases. Medicare's increasingly liberal policy toward PET scans reflects in part the continued maturity of the technology (the availability of whole-body scanners and increased computer processing capability, which have improved PET image reconstruction and  display, for example). But at present, the only Medicare-approved indication for PET scans in neurology practice is the presurgical management of patients with refractory seizures, a transient disturbance of cerebral function caused by an abnormal neuronal discharge. According to the Medicare decision memorandum, "Approximately 25 percent of patients with seizure disorders have intractable (or refractory) seizures [and] 12-25 percent of these patients, in turn, are candidates for surgery, having failed medical therapy."

The memorandum goes on to note, "Several non-invasive diagnostic parameters include brain imaging, clinical/physical examination, neuropsychological testing, and surface electroencephalogram (EEG) testing; however, inconclusive testing can warrant invasive monitoring such as EEG with depth and grid electrodes. Therefore, if PET can provide additional non-invasive confirmation of seizure focus localization, then more patients might avoid preoperative invasive EEG."

Medicare has created its own code to report this service: G0229 (PET imaging; metabolic brain imaging for pre-surgical evaluation of refractory seizures). Medicare payers will not reimburse for CPT PET scan codes most closely associated with G0229 78608 (Brain imaging, positron emission tomography [PET]; metabolic evaluation) and 78609 (... perfusion evaluation) although many private payers will. CMS Specifies Additional Requirements Although Medicare will cover PET scan presurgical evaluation for refractory (that is, nonresponsive to medication) seizures, it will do so only under rigidly defined conditions. Primarily, the patient record must indicate medical necessity. Specifically, the record must show a history of seizures unresponsive to medical therapy, and "The entity submitting [...]