The Centers for Medicare and Medicaid Services (CMS) released MLN Matters article number MM8468 on February 6, 2014 regarding National Coverage Decision changes related to Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors.

The implementation date for non-shared system edits was March 7, 2014. The implementation for shared system edits is July 7, 2014. It is important for physicians, providers and suppliers submitting claims to Medicare A/B Administrative Contractors (MACs) for services to Medicare beneficiaries to be aware of the following changes:

CMS is revising the National Coverage Determinations (NCD) Manual, Section 220.6.17, to reflect that CMS has ended the coverage and evidence development (CED) requirement for 18 Fluorodeoxyglucose FDG PET and PET/CT and PET/MRI for all oncologic indications contained in Section 220.6.17 of the NCD Manual. This removes the current requirement for prospective data collection by the National Oncologic PET Registry (NOPR) for oncologic indications for FDG (HCPCS A9552) only.

  • The CED requirement has ended and modifier -Q0/-Q1, along with condition code 30 (institutional claims only), or V70.7 (both institutional and practitioner claims) are no longer required.

Initial Anti-Tumor Treatment Strategy - PI (formerly “diagnosis” & “staging”)

CMS continues to nationally cover one FDG PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary’s treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initialanti-tumor treatment strategy:

  • To determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure; or
  • To determine the optimal anatomic location for an invasive procedure; or
  • To determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.

Non-covered:

  • Nationally, CMS does not cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate.

Covered with exceptions:

  • Nationally, CMS does not cover FDG PET imaging for diagnosis of breast cancer and initial staging of axillary nodes.
    • Nationally covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for breast cancer are nationally covered.

Nationally, CMS does not cover FDG PET imaging for initial anti-tumor treatment strategy for the evaluation of regional lymph nodes in melanoma.

  • All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.

Nationally, CMS does not cover FDG PET imaging for initial anti-tumor treatment strategy for the evaluation of regional lymph nodes in melanoma.

  • All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.

Subsequent Anti-Tumor Treatment Strategy - PS (formerly “restaging” & “monitoring response to treatment”)

Three FDG PET scans are nationally covered when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy. Coverage of more than three FDG PET scans to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy shall be determined by the local MACs.

Note: Routine follow-up exams are not considered “management of anti-tumor treatment strategy”.

The MLN Matters article MM8468 also provides information related to use of –KX modifier if more than three FDG PET scans is required to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy.

The medical record must include information to allow appropriate reporting of FDG PET services and support the use of applicable modifiers on the claims.

Please review the article and associated documents for complete details:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8739.pdf (PDF, 98 KB)

The official instruction, CR 8739, issued to your MAC regarding this change, is available at in two transmittals at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2932CP.pdf (PDF, 794 KB) and http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R166NCD.pdf (PDF, 37 KB) on the CMS website.

This commentary is a summary prepared by McKesson’s Revenue Management Solutions division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of radiology. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association (“AMA”). The AMA is the owner of all copyright, trademark and other rights to CPT® and its updates.
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About the author

Myra Blankenship, CIRCC, CPC of Compliance-Radiology, McKesson Business Performance Services.