HCFA Plans to Expand Coverage Areas Attention to Detail Increases Timely PET Imaging Pay Up
Published on Thu Mar 01, 2001
Few areas of radiology coding require greater attention to detail than positron emission tomography (PET) imaging, a noninvasive procedure using radiopharmaceuticals to assess the perfusion or metabolic activity in various organ systems. PET is considered a state-of-the-art diagnostic tool and is clinically effective in the management of cancer and cardiac and neurological diseases.
To date, however, it has been regarded as investigational, and both Medicare carriers and private payers have strict guidelines for reporting these services.
It is a very challenging area of radiology coding, notes Stacie L. Buck, RHIA, internal auditor for U.S. Diagnostic Inc., a corporation based in West Palm Beach, Fla., that owns and operates diagnostic imaging centers in several states.
Besides those factors that universally affect other areas of coding (e.g., medical necessity, appropriate diagnoses and frequency considerations), PET imaging also demands that nuclear radiologists and coders take into account additional elements. These include the anatomical site being scanned, previous diagnostic assessments performed, and the type of radiopharmaceutical being injected. In addition, two sets of codes for reporting PET imaging exist CPT Codes to be used with private payers and HCPCS Codes to be used with Medicare beneficiaries.
Finally, coders must be aware that Medicare has a set of modifiers unique to PET imaging codes. Claims submitted without these alpha modifiers will be summarily denied.
Its tempting to try to generalize coding conventions, Buck says. But that would be disastrous with PET imaging. Every study is governed by a different set of guidelines. Coders must be familiar with all the variables and know how they apply to each circumstance. Without this understanding, getting paid is virtually impossible.
Most experts also advise coders to work closely with their radiologist, since codes describing PET demand a thorough understanding of clinical considerations as well.
Specific Applications Covered Incrementally
HCFA initially approved coverage for one application of PET scans in March 1995 imaging of the perfusion of the heart and has incrementally approved other, narrowly defined uses during the ensuing six years. These include initial staging of lung cancer, recurrence of colorectal cancer, staging and characterization of lymphoma, and recurrence of melanoma. Coders should check local medical review policies to determine the specific requirements governing each study.
This list promises to grow rapidly in upcoming months and years, with HCFAs Dec. 15, 2000, announcement that it intends to expand Medicare coverage of PET imaging. Although no effective date or coding guidelines have been officially announced, the policy will expand coverage in the four previously approved cancers (lung, colorectal, lymphoma and melanoma) and add two sites (esophageal, and head and neck). HCFA says coverage of dedicated full circular ring scanners and some partial ring systems will include all clinically appropriate uses [...]
