New FDG Reporting Requirements Delayed

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In CMS
October 5, 2009
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Recent changes to Pub. 100-03 of the Medicare National Coverage Determinations (NCD) Manual may soon affect the way your practice bills for f-18 flouro-D-glucose positron emission tomography (FDG PET) imaging services.

As we reported in the Aug. 3 article “New FDG Reporting Requirements,” the Centers for Medicare & Medicaid Services (CMS) is adopting a new two-part coverage framework, differentiating FDG PET imaging used to inform initial treatment strategies from subsequent treatment strategies.

Who’s affected: Hospitals, independent testing facilities, Medicare Advantage, and outpatient physical therapy.

What’s changed: The effective date for when practices must use two new modifiers to differentiate the initial treatment strategy from subsequent treatment strategies.

All FDG PET oncologic-related claims with dates of service on or after April 6 must include one of the following modifiers: 

  • PI – Positron emission tomography (PET) or PET/computed tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
  • PS – Positron emission tomography (PET) or PET/computed tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines the PET study is needed to inform subsequent anti-tumor strategy
  • Note: The effective date for this reporting requirement is now Oct. 19, rather than Oct. 5.

    What hasn’t changed: ICD-9-CM 185 adencarcinoma of the prostate remains noncovered.

    Append modifier PI to CPT® code 78608 Brain imaging, less than 4 static views; with vascular flow and PET imaging code range 78811 – 78816. Append modifier PS to CPT® PET code(s) in 6632.1.1.

    Don’t forget: The ICD-9-CM cancer diagnosis code.

    Include modifier Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study in addition to the procedure and diagnosis codes and modifier PI or PS when reporting FDG PET imaging for initial or subsequent treatment strategies performed under the coverage of evidence development (CED) paradigm.

    Exception: Institutions should continue to use diagnosis code V70.7 Examination of participant in clinical trial and condition code 30 on claims.

    CMS replaced Transmittal 1772, Change Request 6464, issued July 17, with Transmittal 1817, CR 6632, issued Sept. 18 to inform contractors of this NCD update.

    See Pub. 100-03, NCD Manual, section 220.6.17 for complete details.

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