New Codes for Expanded PET Scan Coverage Allow for Added Reimbursement
Published on Sat Sep 01, 2001
Medicare has issued 21 temporary codes (effective July 1, 2001) for reporting positron emission tomography (PET) scan procedures used to diagnose, stage and restage esophageal, head and neck, lung and colorectal cancers, lymphoma and melanoma. The new G codes replace G0126 (PET lung imaging of solitary pulmonary nodules, using -2-[fluorine-18]-flouro-2-deoxy-d-glucose [FDG] following CT [71250/71260 or 71270]), G0163 (positron emission tomography [PET], whole body, for recurrence of colorectal metastatic cancer), G0164 (positron emission tomography [PET], whole body, for staging and characterization of lymphoma) and G0165 (positron emission tomography [PET], whole body, for recurrence of melanoma or melanoma metastatic cancer).
The G codes listed on page 66 were assigned following Medicare's announcement earlier this year that it would expand coverage for PET scans. Medicare now allows payment for FDG PET scans for staging of non-small-cell lung cancer. The most significant change allows for the use of FDG PET scans when diagnosing malignancy. Previously, Medicare reimbursed for the use of less expensive diagnostic procedures, such as computed tomography (CT) scans, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a coding consulting firm that works extensively with radiation oncology practices in Dallas, Ga.
LMRPs Still Not Revised
PET scans performed after July 1, 2001, should be reported using the new codes. However, Medicare carriers have yet to update their local medical review policies (LMRPs), which determine medical necessity, so radiation oncology practices that bill for these newly covered procedures face uncertain reimbursement, Parman says.
The release of LMRPs could be as late as the end of this year for some carriers, predicts Denise Butler, CPC, team leader and coder for Medical Management Professionals in Knoxville, Tenn.
Parman predicts that many practices face denials because of the absence of LMRPs and the requirement to use the new codes for diagnosis of malignancy despite no medical-necessity guidelines. However, Medicare offers insight into how PET procedures will be approved for reimbursement now.
Be Conservative With Diagnostics
The inclusion of PET scans for diagnosing malignancy is the most radical change. PET scans offer the latest technology in detecting certain types of cancers, but the procedure is expensive. To avoid overuse of this procedure, Medicare and commercial payers have previously limited its use to staging and restaging cancers. While the coverage now includes diagnostic use, the door has been opened only slightly, Parman says.
Radiation oncology practices should be conservative when billing for diagnostic PET scans. According to Medicare's policies for diagnostic coverage, a PET scan is covered only in clinical situations where the results of the procedure would help physicians avoid invasive diagnostic procedures. These would include using PET results to avoid invasive lung biopsy (32405 and 32095-32100) or if results would help determine an optimal [...]
