CMS NCD drops clinical trial requirement for FDG PET scans for solid tumorsMay 6th, 2014 - Scott Kraft
Categories: Billing National Coverage Determinations (NCD)
Patients no longer need to be in a CMS-approved clinical trial for physician practices to get paid for doing as many as four FDG PET scans for solid tumors – one for an initial treatment strategy and three to guide subsequent treatments, according to CMS transmittal 8739 to its Medicare Claims Processing Manual.
In some instances, even more than four scans can be done when they are medically necessary, in line with the Medicare Administrative Contractors (MACs) payment policy for exceptions to the frequency limit and billed using the KX modifier (qualify for an exception under the automatic exception process).
The frequency limit is per cancer diagnosis, so a patient who has multiple cancers can get up to four scans when medically necessary for the treatment of each individual diagnosis. This policy change is a national coverage determination (NCD), meaning it applies to all MACs.
The transmittal took effect April 18, but CMS has backdated the change to June 11, 2013. Any claims done on or after June 11 can be resubmitted to the MAC for reconsideration, but won’t automatically be reprocessed.
The PET scan CPT® codes addressed under the NCD are 78608, 78811, 78812, 78813, 78814, 78815 and 78816.
Under the new policy, when billing the initial PET scan as part of establishing a treatment strategy for the cancer, you would append modifier PI. Each of the three additional PET scans allowed for subsequent treatment strategy would be billed with the modifier PS.
Whether or not a PET scan is billed with modifier PI doesn’t have any bearing on the three PET scan limit for each cancer diagnosis billed with the PS modifier. The fourth PET scan billed with PS will automatically be denied, unless the KX modifier is attached as noted above.
Modifiers Q0 and Q1 for investigational research or clinical trials are no longer required on claims with dates of service on or after June 11, nor is diagnosis code V70.7 for examination of patient in a clinical trial.
When these services are rejected because the PS modifier is not used you may see claim adjustment reason code 4 (the procedure code is inconsistent with the modifier used or a required modifier is missing), remittance advice remark code MA-130 (Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the correct/complete information).
For a list of the diagnosis codes affected by the NCD change, see page 14 of the attached document.
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)Code Sequencing Chapter 15 OB Visits
February 13th, 2023 - Chris Woolstenhulme
Sometimes payer guidelines differ from the official guidelines, this can be confusing, let’s look at a sequencing priority for example in Chapter 15: Pregnancy, childbirth, and the Puerperium (o00-o9A). the guidelines tell us how to code based on the provider's documentation, in addition, it is important to know Chapter 15 codes are never to be used on newborn records, only on the maternal record. Find-A-Code will sequence codes according to the ICD-10-CM guidelines first.Is the End Really Near?
February 7th, 2023 - Chris Woolstenhulme
What happens once the COVID-19 emergency declarations have ended?Will 2023 Be the Year of Outsourced Medical Billing?
February 3rd, 2023 - Find-A-Code
Many healthcare providers have chosen to keep medical coding and billing in-house. From HIPAA compliance to the complexity of ICD-10 codes, it has just been easier to keep track of things by not outsourcing medical billing or coding. But things are changing. So much so that 2023 could be the year that outsourced services finally take over.Three Things To Know When Reporting Prolonged Services in 2023
January 31st, 2023 - Aimee Wilcox
The Evaluation and Management (E/M) changes made in 2021 and again in 2023 brought about new CPT codes and guidelines for reporting prolonged services. Just as Medicare disagreed with CPT in the manner in which prolonged service times should be calculated, they did so again with the new 2023 changes. Here are three things you should know when reporting prolonged services for all E/M services.The Curious Relationship Between CPT Codes and Actual Treatments
January 30th, 2023 - Find-A-Code
Common sense seems to dictate that medical billing codes, like CPT codes for example, are only considered after medical treatment has been provided. After all, the codes are simply a representation of diagnosed conditions and treatment services provided – for billing purposes. But there is a curious relationship between these codes and actual treatments.Why Medical Billing Codes Are Critical To Healthcare Delivery
January 30th, 2023 - Find-A-Code
Medical coders play a critical role in determining how healthcare delivery is reported for record keeping and billing purposes. Likewise, the codes they know so well are equally critical. They have been around for decades. They were originally developed and implemented to make reporting and billing easier in a healthcare system that was becoming incredibly more complex. The system is even more complex today.Why Knowing Medical Terminology Makes Coding Easier
January 27th, 2023 - Find-A-Code
You are excited about beginning your training as a professional medical coder. You're expecting to pass the exam and earn your certification. The future is looking bright until, as you are perusing the educational material, you suddenly realize you're going to have to learn medical terminology.