Wiki Can I bill modifier -PI with a cancer Dx?

[RaeToll]

I received a Medicare claim rejection for CPT code 78816-PIPO (PET/CT whole body) citing inconsistent modifier or required modifier is missing. The primary diagnosis listed on the claim is C61 (malignant neoplasm of prostate). I reviewed the CMS Billing and Coding policy which states, Claims for FDG PET or imaging for oncologic indications for initial treatment strategy must include the “PI” modifier. Claims for FDG PET imaging for oncologic indications for subsequent strategy must include the “PS” modifier.

The physician order reads, 72 years -old Male with high risk prostate cancer, Gleason 9, needing imaging to assess for metastases. The purpose of this scan is for initial anti tumor treatment strategy, initial staging. The imaging findings read, "Ga68 gozetotide PET/CT demonstrates intense abnormal increased PSMA radiotracer uptake in the prostate, consistent with newly diagnosed prostate cancer."
When I run the codes in encoder as billed (78816-PIPO with diagnosis C61) I receive, "Per LCD or NCD guidelines, procedure code 78816 has not met the associated Modifier Code relationship criteria for CMS ID(s) 220.6.17."
When I change the modifier to -PS the claim comes up clean.

Am I not supposed to bill modifier -PI with a cancer diagnosis? I can't find CMS documentation that says either way and I feel the documentation supports the use of modifier PI.
I appreciate anyone that can shed some light on this issue.

 

[sls314]

I received a Medicare claim rejection for CPT code 78816-PIPO (PET/CT whole body) citing inconsistent modifier or required modifier is missing. The primary diagnosis listed on the claim is C61 (malignant neoplasm of prostate). I reviewed the CMS Billing and Coding policy which states, Claims for FDG PET or imaging for oncologic indications for initial treatment strategy must include the “PI” modifier. Claims for FDG PET imaging for oncologic indications for subsequent strategy must include the “PS” modifier.

The physician order reads, 72 years -old Male with high risk prostate cancer, Gleason 9, needing imaging to assess for metastases. The purpose of this scan is for initial anti tumor treatment strategy, initial staging. The imaging findings read, "Ga68 gozetotide PET/CT demonstrates intense abnormal increased PSMA radiotracer uptake in the prostate, consistent with newly diagnosed prostate cancer."
When I run the codes in encoder as billed (78816-PIPO with diagnosis C61) I receive, "Per LCD or NCD guidelines, procedure code 78816 has not met the associated Modifier Code relationship criteria for CMS ID(s) 220.6.17."
When I change the modifier to -PS the claim comes up clean.

Am I not supposed to bill modifier -PI with a cancer diagnosis? I can't find CMS documentation that says either way and I feel the documentation supports the use of modifier PI.
I appreciate anyone that can shed some light on this issue.

I looked up the NCD 220.6.17, and it looks like the initial anti tumor treatment strategy is not covered for prostate cancer:

NCD - Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17)

Use this page to view details for NCD - Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17).

www.cms.gov

2. Initial Anti-Tumor Treatment Strategy
CMS continues to believe that the evidence is adequate to determine that the results of FDG PET imaging are useful in determining the appropriate initial anti-tumor treatment strategy for beneficiaries with suspected cancer and improve health outcomes and thus are reasonable and necessary under §1862(a)(1)(A) of the Social Security Act (the Act).
Therefore, CMS continues to nationally cover one FDG PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary’s treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial anti-tumor treatment strategy:

• To determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure; or
• To determine the optimal anatomic location for an invasive procedure; or
• To determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.

See the table at the end of this section for a synopsis of all nationally covered and non-covered oncologic uses of FDG PET imaging.
Indications and Limitations of Coverage

1. CMS continues to nationally cover FDG PET imaging for the initial anti-tumor treatment strategy for male and female breast cancer only when used in staging distant metastasis.
2. CMS continues to nationally cover FDG PET to determine initial anti-tumor treatment strategy for melanoma other than for the evaluation of regional lymph nodes.
3. CMS continues to nationally cover FDG PET imaging for the detection of pre-treatment metastasis (i.e., staging) in newly diagnosed cervical cancers following conventional imaging.

C.1 Initial Anti-Tumor Treatment Strategy Nationally Non-Covered Indications

1. CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate.
2. CMS continues to nationally non-cover FDG PET imaging for diagnosis of breast cancer and initial staging of axillary nodes.
3. CMS continues to nationally non-cover FDG PET imaging for initial anti-tumor treatment strategy for the evaluation of regional lymph nodes in melanoma.
4. CMS continues to nationally non-cover FDG PET imaging for the diagnosis of cervical cancer related to initial anti-tumor treatment strategy.

 

[RaeToll]

I looked up the NCD 220.6.17, and it looks like the initial anti tumor treatment strategy is not covered for prostate cancer:

NCD - Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17)

Use this page to view details for NCD - Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17).

www.cms.gov

2. Initial Anti-Tumor Treatment Strategy
CMS continues to believe that the evidence is adequate to determine that the results of FDG PET imaging are useful in determining the appropriate initial anti-tumor treatment strategy for beneficiaries with suspected cancer and improve health outcomes and thus are reasonable and necessary under §1862(a)(1)(A) of the Social Security Act (the Act).
Therefore, CMS continues to nationally cover one FDG PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary’s treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial anti-tumor treatment strategy:

• To determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure; or
• To determine the optimal anatomic location for an invasive procedure; or
• To determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.

See the table at the end of this section for a synopsis of all nationally covered and non-covered oncologic uses of FDG PET imaging.
Indications and Limitations of Coverage

1. CMS continues to nationally cover FDG PET imaging for the initial anti-tumor treatment strategy for male and female breast cancer only when used in staging distant metastasis.
2. CMS continues to nationally cover FDG PET to determine initial anti-tumor treatment strategy for melanoma other than for the evaluation of regional lymph nodes.
3. CMS continues to nationally cover FDG PET imaging for the detection of pre-treatment metastasis (i.e., staging) in newly diagnosed cervical cancers following conventional imaging.

C.1 Initial Anti-Tumor Treatment Strategy Nationally Non-Covered Indications

1. CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate.
2. CMS continues to nationally non-cover FDG PET imaging for diagnosis of breast cancer and initial staging of axillary nodes.
3. CMS continues to nationally non-cover FDG PET imaging for initial anti-tumor treatment strategy for the evaluation of regional lymph nodes in melanoma.
4. CMS continues to nationally non-cover FDG PET imaging for the diagnosis of cervical cancer related to initial anti-tumor treatment strategy.

Thank you for your help Susan. I truly appreciate you.