CMS Issues Post NCD Decision FDG PET DOS Claims Instructions
CMS has issued an eNews Provider Update (see page 10) with claims instructions following its June 11, 2013 Decision Memo for PET FDG for Solid Tumors (CAG-00181R4). This notification is intended to help guide providers until a more detailed transmittal is published at a later date.
In their Decision Memo, CMS ended the coverage with evidence development (CED) requirement for F-18 fluorodeoxyglucose positron emission tomography (FDG PET) and FDG PET/CT for all oncologic indications contained in Section 220.6.17 of the Medicare National Coverage Determinations (NCD) Manual. This decision memo became effective on June 11, 2013 and removes the current requirement for prospective data collection by the National Oncologic PET Registry (NOPR) for oncologic indications of FDG only.
On or after June 11th, 2013, FDG PET and FDG PET/CT claims with CPT codes 78608, 78811, 78812, 78813, 78814, 78815, 78816 and HCPCS code A9552 no longer require the following modifier and diagnosis code:
· Q0 (zero): Investigational clinical service provided in a clinical research study that is an approved clinical research study.
· V70.7: Examination of participant in clinical research.
These changes only apply to services using FDG (HCPCS A9552) as the radiopharmaceutical. This does not apply to services using NaF-18 (HCPCS A9580). The changes also do not affect use of the following modifiers, which are still required on claims.
· • PI (initial treatment strategy)
· • PS (subsequent treatment strategy)
Note: This decision does not change coverage for use of PET or PET/CT using radiopharmaceuticals NaF-18 (fluorine-18 labeled sodium fluoride), ammonia N-13, or rubidium-82 (Rb-82).
CED continues under NOPR for NaF-18 PET and PET/CT for bone metastasis per section 220.6.19 of the NCD Manual.
The NCD Internet Only Manual will be updated soon to reflect these changes. See the CMS final decision memorandum for more detailed information.
