Since the PET national coverage determination from the Centers for Medicare & Medicaid Services (CMS) became effective, PET providers will be following the new PET coverage rules but Medicare contractors will be using the current PET claims guidance for dates of service on or after April 6, according to SNM.
The society said that CMS will not likely publish Medicare Claims Guidance until later this month and that Medicare contractors will have 30 days to implement any new Medicare Claims Guidance, resulting in likely effective implementation dates in May/June.
In the interim, SNM has recommended either of two options;
(1) Bill the Medicare contractor now in accordance with the new PET coverage guidelines and using the current billing instructions (with the Q0 and V70.7 rules), expect these claims to reject initially and wait for instructions from your local Medicare contractor regarding re-processing for payment; or
(2) Hold claims until CMS issues further guidance later this month.
CMS also has published two new modifiers with effective dates of service July 2009. According to SNM, providers should not use these two new modified before receiving the CMS instructions; these claims will be rejected because these modifiers are not yet active, nor are they in the Medicare Contractors' systems.
To clarify the new billing instructions for those cancers that are specifically non-covered for the initial treatment strategy evaluation, the society has suggested that:
• For assessing regional lymph nodes in melanoma, submit as G0219, PET imaging whole body; melanoma for non-covered indications.
• For diagnosis of breast cancer (evaluation of a suspicious abnormality on physical examination, mammography, or other imaging study), submit as G0252, PET imaging, full & 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); and
• For the diagnosis of prostate cancer and initial staging of newly diagnosed prostate cancer, submit as G0235 PET imaging, any site, not otherwise specified.
SNM said that the G0235 code should also be used for any other non-covered study, such as (1) a PET study for initial treatment strategy evaluation if the patient has previously had another study done for this purpose for the same cancer or (2) a PET study done for "routine" surveillance of a patient with a previously treated cancer in whom there is no evidence to suggest residual or recurrent disease.
SNM said it will host a webinar on April 27 highlighting the final PET NCD and the new NOPR requirements.