Oncology & Hematology Coding Alert

Medicare has expanded coverage for 2-[fluorine-18]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) scans allowing radiation oncologists to be reimbursed soon for diagnosing, staging and restaging of esophageal cancer and head and neck cancers. They now allow reimbursement for FDG PET scans for staging of non-small cell lung cancer and will now cover them as a diagnostic tool as well.

Radiation oncology practices that have these scans cannot, however, begin billing for this procedure until July 2001 when Medicare determines exactly how they should be coded under these new diagnoses. The American Society of Clinical Oncologys (ASCO) public policy and practices department advises that current FDG PET procedure codes are G0030-G0047. Also, HCFA has yet to assign a reimbursement amount for use of these scans on esophageal, and head and neck cancers.

According to ASCO, reimbursement is limited to selected high-performance PET scanners. Based on available studies, Medicare determined that full-ring scanners perform better than other types.

Use for FDG PET scans diagnosis is limited. They will be covered in clinical situations in which an oncology physician is trying to avoid an invasive diagnostic procedure, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a coding consulting firm in Dallas, Ga. Other diagnostic procedures, such as screenings, will not be paid for unless the patient has specific symptoms. For staging and restaging, coverage is based on two conditions:

The stage of the cancer remains in doubt after the completion of a standard diagnostic workup, including conventional imaging; and

Clinical management of the patient would differ depending on the stage of the cancer identified.

Parman says the key to showing medical necessity for diagnosis, staging and restaging is to include in the patient record specific clinical questions that the physician expects to be answered by the PET scan. For example: Is it necessary to biopsy a pulmonary nodule? The results should also be included to show the answer to the original question. A positive result will lend evidence to the need for more invasive procedures.

HCFA will keep close tabs on this new coverage, Parman warns, by reviewing records where PET scans have been used. The clinical questions must relate to the requirements described above. In a Dec. 15 decision, HCFA wrote that they plan to conduct a review within the first year following the effective date of this new policy, and will use the results to determine whether there is need for further review and to decide if revisions would be indicated.

As radiation oncology practices gear up to include these diagnoses in determining the presence and severity of these cancers, they should study reimbursement requirements for other diagnoses already covered by Medicare.

They now cover [...]