Oncology & Hematology Coding Alert

NOPR stats help boost coverage for your patients.

Whether your clinic performs its own PET scans or you need to keep up with coverage for tumor imaging your oncologist orders, CMS has news you cant miss.

News: CMS is crediting data submitted to the National Oncologic PET Registry (NOPR) for a recent expansion of PET coverage for initial anti-tumor treatment strategy.

This expansion in coverage for PET scans shows that the Coverage with Evidence Development program is a success, according to CMS acting administrator Charlene Frizzera in an April 6 release. CED allowed us to cover an emerging technology, learn more about its usage in clinical practice, and adjust our coverage policies accordingly.

Dont Miss the 1 Scan Rule

Be sure you catch two changes in the policy:

1. Framework: Instead of having categories for diagnosis, staging, restaging, and monitoring response to treatment, CMS now has a two-part framework:

" Initial Anti-Tumor Treatment Strategy, formerly diagnosis and staging

" Subsequent Anti-Tumor Treatment Strategy, formerly restaging and monitoring response to treatment.

2. Coverage: CMS will cover one FDG PET study for beneficiaries with solid tumors that are either:

" biopsy proven OR

" strongly suspected based on other diagnostic testing.

For coverage, the treating physician must determine that the patient needs the FDG PET study for one of these reasons:

" To determine whether the beneficiary is an appropriate candidate for an invasive procedure (diagnostic or therapeutic)

" To determine an invasive procedures optimal anatomic location

" To determine the tumors anatomic extent when the recommended anti-tumor treatment depends on this extent.

Exceptions: PET isnt covered for all solid tumors. See below for the coverage rundown.

Some Coverage Has Strings Attached

CMS now covers initial and subsequent treatment strategy scans for the following solid tumor types: colorectal, esophageal, head and neck (not thyroid or CNS), lymphoma, non-small cell lung, ovary, and myeloma.

For the following types, CMS covers an initial scan, but subsequent treatment scans still fall under CED/NOPR: brain, small cell lung, soft tissue sarcoma, pancreas, and testes.

But a few cancer types have special coverage rules, as demonstrated in the chart below.

All other solid tumors are covered for initial treatment scans, but they fall under CED/NOPR for subsequent treatment scans.

Dont give up: SNM plans to continue to partner with concerned organizations to seek coverage for other types of cancers for which PET has a proven medical and therapeutic value, according to Robert W. Atcher, PhD, MBA, president of SNM and University of New Mexico/Los Alamos National Laboratory professor of pharmacy, in a press release.

SNM offers the following coding advice for the noncovered services:

" For assessing regional lymph nodes in melanoma, report G0219 (PET imaging whole body; melanoma for non-covered indications).

" For breast cancer diagnosis, report G0252 (PET imaging, full and partial-ring PET scanner only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer [e.g., initial staging of axillary lymph nodes])

" For prostate cancer diagnosis and initial staging, report G0235 (PET imaging, any site, not otherwise specified), which is also appropriate for other non-covered studies.

Decide Whether to Hold Your Claims

CMSs new PET NCD became effective April 6, but experts predict an implementation date later in the spring or summer, allowing CMS to publish guidance and contractors to update their systems.

SNM suggests that until contractors get up to speed, you have two reporting options:

1. Bill Medicare for the newly covered PET scans you perform with modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) and V70.7 (Examination of participant in clinical trial) along with the appropriate principal diagnosis code, but expect rejections and stay alert for instructions on reprocessing claims, OR

2. Hold your claims for a few weeks until CMS issues guidance.

Resource: You can find this information in the April 9 article Billing for PET Studies in Medicare Patients, Pending Medicare Claims Guidance on SNMs Government Relations News page (http://interactive.snm.org/index.cfm?PageID=8612).

Prep for Julys PI and PS Modifiers

Along with coverage changes, youll have two new modifiers related to oncologic PET scans soon. These modifiers become effective July 1, so dont try to append them before that date.

The two new modifiers will indicate either an initial or subsequent scan:

" Initial: PI -- Positron emission tomography (PET) or PET/computed tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing, one per cancer diagnosis

" Subsequent: PS -- Positron emission tomography (PET) or PET/computed tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiarys treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy.

Check here: You can find the decision memo online at www.cms.hhs.gov/mcd/viewnca.asp?nca_id=218.

You can find NOPR information online at www.cancerpetregistry.org/index.htm. NOPR also offers acoverage chart with ICD-9 codes available at http://interactive.snm.org/docs/Appendix_III_NOPR_Table_4-4-09_FINAL.pdf. But remember that your local carrier may post its own list of which ICD-9 codes it covers.