IBA Molecular is pleased to provide reimbursement and coding information for the products that you use each day. Remember that each provider is responsible for the correct coding for services provided. Also, you should check with your third-party payers to ensure you are in compliance with their billing guidelines and/or regulations.

MEDICARE IN THE HOSPITAL OUTPATIENT DEPARTMENT (HOPPS)

Fluorodeoxyglucose F-18 FDG

New for 2011 | CMS reconsidered the non-coverage situation during 2010, and clarified some of its regulatory language. However, there are no substantive changes for PET FDG that will occur in 2011.

Oncology | CMS continues to cover one PET FDG study to determine initial treatment planning for oncology patients.  CMS announced that for dates of service of August 4, 2010 or later, that local Medicare contractors will have coverage and payment discretion regarding additional PET FDG scans in determining initial treatment planning.

The tumor types that are covered under the Coverage with Evidence Development (CED) system, for which the National Oncologic PET Registry (NOPR) is providing a data collection and reporting system, has not changed for FDG PET in 2011.  You can find all of the NOPR information by clicking here.

Cardiology | FDG PET has been covered since 2005 for primary or initial diagnosis of myocardial viability.  Please note that if a PET is the primary mode of diagnosis, CMS will not cover a subsequent SPECT.

Neurology | FDG PET is covered for Alzheimer’s Disease (AD) and fronto-temporal dementia (FTD) as specified by CMS in the Internet Only Manual (Chapter 1, Part 4, Section 220.6.13).

FDG PET has been and continues to be covered since 2001 for pre-surgical evaluation for refractory seizures

For more information, please contact your IBA Molecular Account Executive for PETLinQ IQ access, where you can receive by the minute answers to your reimbursement questions.

Rubidium Rb-82

New for 2011 | CMS has not made any changes to its policy regarding the use of Rb-82 in cardiology PET scans.  This PET tracer is covered by CMS for the following use:

Cardiology | Rb-82 is covered for myocardial perfusion.  Please note that if a PET is the primary mode of diagnosis, CMS will not cover a subsequent SPECT.

Sodium Fluoride NaF-18

Medicare Coverage: New for 2011 | In February 2010, the Centers for Medicare and Medicaid Services (CMS) amended its regulations to allow for payment for the use of Sodium Fluoride (NaF-18) in PET scans “to inform the initial antitumor treatment strategy or to guide subsequent antitumor treatment strategy after the completion of initial treatment, and when the beneficiary is enrolled in, and the NaF-18 PET provider is participating in, [a CMS-approved] prospective clinical study.” (CMS Internet Only Manual, Section 220.6.19.) The National Oncologic PET Registry (NOPR) has been working with CMS to establish such a study, and has announced that the study will open on February 7, 2011.

The primary objective of the NOPR study is “to assess the effect of NaF-PET on referring physicians’ plans of intended management of patients with known or suspected bone metastases.” (NOPR website, www.cancerpetregistry.org).

Therefore, effective February 7, 2011, NOPR will launch and open this CMS-approved study, and sites will be eligible for Medicare reimbursement under the following conditions:
 

• Medicare-eligible PET facilities can participate (for a fee, just like with the FDG studies). If a facility is already registered, there is no need to register again.
• Facilities will be required to complete pre-PET, PET evaluation, and post-PET data collection activities.
• For Medicare payment, treatment must be for Medicare beneficiaries only. Appropriate consent must be obtained as specified by NOPR.

For more information, please contact your IBA Molecular Account Executive for PETLinQ IQ access, where you can receive by the minute answers to your reimbursement questions.

HCPCS Codes

The following table lists the HCPCS codes for products currently on the market.  However, please note that CMS has bundled the cost of products into the payment for the PET procedure, except where noted.  However, CMS will only pay for the diagnostic procedure when a PET radiopharmaceutical (RP) is listed on the claim.  Therefore, even though the product would be bundled into the procedure payment, the HCPCS code for the product should be present on the claim. 

CPT Codes

The following table lists the CPT (procedure) codes for PET services.  (All CPT codes copyright, American Medical Association, 2010.) 
2011 Final PET Payment Rates and Coding Summary for the CMS Hospital Outpatient Prospective Payment System (HOPPS)

Code Modifiers

When making a Medicare claim, it is important to use the following code modifiers to describe the service provided to a greater level of detail.  These modifiers are part of CMS’s regulatory requirements and must be included on the claim.  By providing this modified detail, payment to you is likely to encounter fewer delays.

PRIVATE (COMMERCIAL) INSURANCE

Each private insurance company develops its own policy regarding the use of molecular PET tracers.  You should check with the individual carrier with which your facility participates for the exact coverage policy and billing guidance.  In general, those insurers that cover PET tracers do not require CED studies as Medicare does.

For more information, please contact your IBA Molecular Account Executive for PETLinQ IQ access, where you can receive by the minute answers to your reimbursement questions.

LINKS TO POLICIES

Medicare Coverage for PET  (Once at the link, jump to Section 220.6.)

Aetna Coverage for PET

CIGNA Coverage for PET

United Healthcare Coverage for PET

IBA Molecular, North America, Inc. Disclaimer: This information is provided by IBA Molecular North America Inc. (together with its affiliates “IBA”) as educational guidance only and is not intended to increase or maximize reimbursement by any payer. Diagnosis and procedure coding is dependent on documentation in the patient's medical record. Federal law prohibits fraudulent statements made on insurance claim submissions, and violations can result in both civil and criminal penalties. IBA strongly recommends that you consult your third-party payers with regard to local coverage, coding and reimbursement policies and follow all applicable federal, state and local laws when billing for reimbursement and review and confirm reimbursement policies with your own legal or other professional advisors.  Please note Medicare's Correct Coding Initiative is reviewed and updated several times a year and commercial payer policies vary and should be carefully reviewed. Revised 12/15/2000