New Modifiers and Billing Instructions for PET Scans

on Wednesday, 05 August 2009. All News Items

Effective April 6, 2009, CMS expanded the coverage of PET scans for initial treatment (diagnosis and staging) and subsequent treatment (restaging and monitoring response to treatment) for most solid tumors.  FDG PET scans for certain cancers, especially for subsequent treatments, must still be provided under the coverage with evidence development/coverage with study participation (CED/CSP) paradigm.  Please see the table at the end of this article for a summary of coverage by tumor type.

On July 17, 2009 CMS released two transmittals, Transmittal R1772 and Transmittal R104 (CR 6464), manualizing the NCDs and providing billing instructions.  The transmittals introduce three new modifiers for reporting PET scans. (KX is actually an existing modifier, but its use in relation to PET scans is defined in these transmittals.)   Hospitals are required to begin using the new modifiers October 5, 2009 for claims with date of service on or after April 6, 2009.

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.  Short descriptor: PET tumor init tx strat

PS – Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy. Short descriptor: PET tumor subsq tx strategy

KX – requirements specified in the medical policy have been met. (Use in addition to the –PI or –PS modifier when an alternate ICD-9 diagnosis code outside the 140.xx through 239.xx range is used based on a local coverage determination.)

Claims for PET Scans for Initial Treatment Strategy for Covered Cancers:

  • CPT codes 78811, 78812, 78813, 78814, 78816
  • Modifier –PI
  • Coverage limited to only (1) one time per cancer type
  • An appropriate ICD-9 diagnosis code from the range 140.xx through 239.xx OR
  • An ICD-9 diagnosis code determined by the local contractor and modifier –KX in addition to –PI modifier

Claims for PET Scans for Subsequent Treatment Strategy for Covered Cancers:

  • CPT codes 78811, 78812, 78813, 78814, 78816
  • Modifier –PS
  • An appropriate ICD-9 diagnosis code from the range 140.xx through 239.xx OR
  • An ICD-9 diagnosis code determined by the local contractor and modifier –KX in addition to –PS modifier

Claims for PET Scans for Initial or Subsequent Strategy under CED:

  • CPT codes 78811, 78812, 78813, 78814, 78816
  • Modifier –PI or –PS as appropriate
  • An appropriate ICD-9 diagnosis code from the range 140.xx through 239.xx
  • Modifier –QO, diagnosis code V70.7 and condition code 30
  • National Oncologic PET Registry (NOPR) data collection required

Hospitals need to develop internal processes to:

  • determine the reason for an oncologic PET scan when it is ordered – i.e. diagnosis or staging (initial treatment strategy) or restaging or monitoring response to treatment (subsequent treatment strategy)
  • ensure the appropriate modifier(s) are present on the claim
  •  verify an appropriate diagnosis is provided and coded

Appendix A: Effect of Coverage Changes on Oncologic Uses of FDG PET
See NCD Manual for specific coverage language.

Final Framework
Solid Tumor Type Initial Treatment Strategy* Subsequent Treatment Strategy**
Colorectal Cover Cover
Esophagus Cover Cover
Head & Neck (not thyroid or CNS) Cover Cover
Lymphoma Cover Cover
Non-small cell lung Cover Cover
Ovary Cover Cover
Brain Cover CED
Cervix (1) or CED Cover
Small cell lung Cover CED
Soft Tissue Sarcoma Cover CED
Pancreas Cover CED
Testes Cover CED
Breast (female and male) (2) Cover
Melanoma (3) Cover
Prostate N/C CED
Thyroid Cover (4) or CED
All other solid tumors Cover CED
Myeloma Cover Cover
All other cancers not listed herein CED CED

 * Formerly “diagnosis” and “staging”
** Formerly “restaging” and “monitoring response to treatment when a change in treatment is anticipated”
N/C = noncover

(1) Cervix: Covered for the detection of pre-treatment metastases (i.e., staging) in newly diagnosed cervical cancer subsequent to conventional imaging that is negative for extra-pelvic metastasis. All other uses are CED.
(2) Breast: Noncovered for diagnosis and/or initial staging of axillary lymph nodes. Covered for initial staging of metastatic disease.
(3) Melanoma: Noncovered for initial staging of regional lymph nodes. All other uses for initial staging are covered.
(4) Thyroid: Covered for subsequent treatment strategy of recurrent or residual thyroid cancer of follicular cell origin previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin >10ng/ml and have a negative I-131 whole body scan. All other uses for subsequent treatment strategy are CED.

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