Volume 3, Issue 3 SUMMER 2006 pet center of excellence newsletter SNM Members Appointed to National Academy of Sciences PET Coding Review Committee to Review State of Nuclear Medicine and Resources By Denise A. Merlino, MBA, CNMT, CPC, FSNMTS Peter S. Conti, immediate past president of ET is a technology that continues to evolve, and coding, coverage, and payment both SNM and the PET Center of Excellence, Psystems have been evolving along with it. In March of 2005, PET providers and a number of other SNM members were transitioned from using complicated “G” series Healthcare Common Procedure Cod- recently named to the National Academy of ing System (HCPCS) codes to the American Medical Association (AMA) Current Sciences (NAS) ad hoc committee of experts Procedural Terminology (CPT) codes for Medicare-covered indications. Last January, to review the “state of the science” for nuclear PET radiopharmaceutical HCPCS codes were changed for FDG and rubidium. Finally, medicine. in May, the National Oncologic PET Registry (NOPR) went into operation providing “The 13-month $700,000 study will pro- Medicare coverage of FDG PET studies for all cancer indications that did not fall under vide the opportunity to validate the importance the current national coverage determination (NCD) policy. of basic nuclear medicine research,” said Every change brings with it the need to train staff, update billing software, and make Conti, a professor of radiology, pharmacy and certain that all billing procedures are in compliance with the new regulations. The list biomedical engineering at the University of below summarizes the top 10 things you need to know about coding PET today. On the Southern California, Los Angeles. “Nuclear following page you will find a list of PET coding resources and, on page 3, a table listing medicine research has a proven record of all of the current PET codes and descriptions. leading to improvements—from bench to bed- 1. The Medicare National Coverage Determination (NCD) Manual is your bible for side—in the diagnosis and treatment of life- indications on which CMS has already reached a coverage determination. (Such threatening cancer and debilitating heart and indications are not eligible for NOPR.) Every PET facility should have this CMS neurological diseases that affect millions each document on hand when coding PET procedures. year.” 2. The PET NCD policy is considered an exclusionary policy; therefore, if a PET The study, which will be funded by the radiopharmaceutical or indication is not mentioned in the national coverage Department of Energy (DOE) and National policy and is not eligible under the new NOPR program, that procedure is not Institutes of Health (NIH), was prompted by a covered by Medicare. An example of this is “sodium fluoride F-18 bone scan $23 million cut in funding from DOE’s 2006 imaging.” Medicare does not currently cover this procedure. (Other third party fiscal year budget, effectively eliminating all payers may; however, I am not currently aware of any.) money for basic nuclear medicine and molecu- 3. Your local coverage determination (LCD) policies or carrier bulletins and news- lar imaging research. Basic molecular imag- letters (published by the Medicare contractor) are key sources for ICD 9 CM ing/nuclear medicine research has been funded diagnosis codes and any frequency limits. Carriers have discretion so these can by the DOE since biomedical research was vary from state to state. (Notice the NCD for PET does not mention ICD 9 diag- initially included in the Atomic Energy Act nosis codes except for PET for Alzheimer’s and neurodegenerative diseases.) If of 1954. (The Atomic Energy Commission was your contractor does not publicly publish this information or furnish it upon DOE’s predecessor.) The study is expected to request, you can obtain it through the Freedom of Information Act. provide findings and recommendations on the 4. Use AMA CPT codes for Medicare covered indications; for noncovered indica- following issues: tions use G (HCPCS) level II codes. • Future needs for radiopharmaceutical 5. Know the difference between diagnosis, staging, restaging, and monitoring. (Medicare development for the diagnosis and treat- does not pay for surveillance.) Details can be found in the NCD for PET. ment of human disease; (Continued on page 2. See Coding.) • Future needs for computational and instrument development for more precise localization of radiotracers in normal and PET on the Net 4 aberrant cell physiologies ; Views You Can Use 5 • National impediments to the efficient PET in the Literature 6 entry of promising new radiopharmaceu- SNM Speaks Out on PET 7 (Continued on page 2. See ) JNM Publishes NCI-Sponsored Guidelines for Using FDG PET 10 NASC. In this issue (Coding. Continued from page 1.) 6. Always bill separately for the PET radiopharmaceutical. With so many questions in the PET community’s mind about Historically, payers bundled payment for PET radiophar- how to correctly code PET procedures, the SNM Coding and maceuticals with the PET procedure when billing with G Reimbursement Workgroup set out to answer over 25 common codes. After the transition to CPT codes, most Medicare questions and answers. Logged-in SNM members and Coding contractors set payment rates for radiopharmaceuticals Corner members can access SNM’s newly updated PET and PET/ separate from the procedures. There are a few states such CT Q & A at www.snm.org—click PRACTICE MANAGEMENT, as Florida that continue to bundle payment for FDG; stay then CODING CORNER. tuned, as this is likely to change. So how does a PET facility get the details on the 10 impor- 7. Know your technology. What is the difference between a tant issues listed above and keep pace with all these and future PET scan and a CT scan versus a PET/CT on an integrated changes? PET facilities should obtain and keep current a library system? The codes will change based on the type of equip- of important resources for PET. Additionally, they should check ment used and how and when the scan was acquired. frequently with CMS and their professional societies for changes 8. Know the important modifiers for PET procedures. For and updates to any of these documents. The following list of ref- example, “59” identifies a diagnostic CT on the same day erences should be considered staples in any PET facility billing as a PET or PET/CT scan, and the “QR” modifier is for department. NOPR patients. 9. For cardiac PET imaging, providers cannot use the wall motion and ejection fraction codes used with SPECT procedures. Instead, consider using “CPT 78499, unlisted nuclear medicine cardiac procedures.” PET Coding Resources 10. For FDG tumor brain imaging use CPT 78608, not the more general PET tumor codes CPT 78811-78816. As with Medicare National Coverage Determinations Manual Section any nuclear medicine coding, always use organ-specific 220.6 coding if available. www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf Medicare Claims Processing Manual, Chapter 13 Radiology and other Diagnostic Procedures (NASC. Continued from page 1 ) . www.cms.hhs.gov/manuals/downloads/clm104c13.pdf tical compounds into clinical feasibility studies and strate- gies to overcome them; and CMS Medical Learning Network MLN Matters Expanded • The impact of shortages in radioisotopes or highly trained Coverage for PET Scans MM 3741 radiochemists on nuclear medicine research, and short- and www.cms.hhs.gov/MLNMattersArticles/downloads/MM3741.pdf long-term strategies to alleviate such shortages. National Listing of all NCD’s, and LCD’s Other SNM members on the NAS committee include Joanna S. www.cms.hhs.gov/mcd/search.asp Fowler, a senior chemist at Brookhaven National Laboratory and director of the Brookhaven PET Program, Upton, NY; S. James CMS Radiopharmaceutical Transmittals Adelstein, Paul C. Cabot Distinguished Professor of Medical Bio- www.cms.hhs.gov/Transmittals/2006Trans/list.asp physics at Harvard Medical School, Boston, MA; Joel Karp, chief Hospitals Transmittal 822 CR 4270 of the physics and instrumentation research section in the Depart- Physician offices Transmittal 923 CR 5054 ment of Radiology and director of the Department of Radiology PET Center at the University of Pennsylvania, Philadelphia, PA; SNM, Practice Management, Coding Corner, PET Facilities Thomas Lewellen, professor of radiology, adjunct professor of http://interactive.snm.org/index.cfm?PageID=3416 electrical engineering, and director of physics and instrumentation development in nuclear medicine at the University of Washington, SNM PET Coding Educational Materials Seattle; C. Douglas Maynard, former chair of the radiology depart- http://interactive.snm.org/index.cfm?PageID=3399 ment and currently professor emeritus of radiology at Wake Forest University School of Medicine, Winston-Salem, NC; Marcus E. National Oncologic PET Registry Raichle, professor of radiology, neurology, neurobiology, biomed- www.cancerPETregistry.org ical engineering, and psychology and codirector of the Division of Medicare Transmittal 956 CR 5124 Radiological Sciences in the Mallinckrodt Institute of Radiology www.cms.hhs.gov/transmittals/downloads/R956CP.pdf at the Washington University School of Medicine, St. Louis, MO; Thomas J. Ruth, director of the PET Program at the University of MLM Matters MM5124 British Columbia, Vancouver; and Heinrich Schelbert, professor www.cms.hhs.gov/MLNMattersArticles/downloads/MM5124.pdf of molecular and medical pharmacology at the University of Cali- fornia at Los Angeles. Other committee members include: