Question Summary
Q. How can I receive the Medicare guidelines for coverage of PET Scans...
Q. Where can I get the whole reimbursement rates for various CPT?
Q. ...guidelines for PET/CT imaging in restaging Hodgkins Disease?
Q. What does ICD code 174.8 refer to?
Q. Regarding F-Dopa for PET imaging, would this be a patient self-pay...
Q. ...Does Medicare reimburse for recurrent Cervical Cancer...
Q. Does the capped OPPS rate for the TC component for PET include FDG...
Q. What is the actual reimbursement from Medicare for a PET/CT...
Q. We are currently evaluating PEM...
Q. Texas Medicaid fee schedule shows a reimbursement rate...
Q. ...How will the Medicare Reimbursement affect us...
Q. ...The final rule for 2007 HOPPS has now been released...
Q. ...Medi-Cal Program reimburse for PET/CT exams with or without TAR?
Q. How do you imagine the 2007 Medicare proposed changes....
Q. How will the Medicare proposed changes for payment ...
Q. How will the proposed Medicare Physician Fee Schedule for 2007 impact...
Question and Answers
Q. How can I receive the Medicare guidelines for coverage of PET Scans in an outpatient imaging center located in Florida? If you suggest Medicare, please give me any hints as to whom I must speak with and how to contact that person. I have spent more than 3 hours today on the phone holding and talking to representatives from Medicare and am getting nowhere fast. Thanks for any help you can lend.
A. The Medicare coverage for PET is determined at the national level by CMS. The coverage is binding on all Medicare contractors. The coverage guidelines are set forth in the Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.6 (launches PDF). It begins on page 23 of the document.
The CPT/HCPCS coding guidelines are set forth in the Medicare Claims Processing Manual, Chapter 13, Section 60 (launches PDF). It begins on page 16 of the document.
At the local level, some Medicare contractors have published Local Coverage Determinations (LCD) on PET, which may include such things as ICD.9 coding guidelines for the nationally covered indications. Florida Medicare (First Coast Service Options Inc) has published only an LCD on PET myocardial imaging. They do not have an LCD published on any of the other covered PET indications.
For questions specific to Florida Medicare, you can contact the provider help line at (866) 454-9007, or by e-mail. You also might try contacting Sidney Sewell, MD, the Florida Medicare medical director at: (904) 791-8006 or via e-mail.
Q. Where can I get the whole reimbursement rates for various CPT?
A. The Medicare reimbursement rates for all CPT/HCPCS codes under the Hospital Outpatient Prospective Payment System (HOPPS) can be found in addendum B of the 2007 HOPPS final rule.
If you are interested in the Medicare reimbursement rates to physicians and clinics, that information can be found in the physician fee schedules posted on the various Medicare Part B carrier websites. For example, in New York City, the Medicare Part B carrier is Empire Medicare, and you can view the 2007 fee schedules for the jurisdiction that Empire covers by visiting its Web site.
Q. What are the Medicare guidelines for PET/CT imaging in restaging Hodgkins Disease?
A. The complete coverage guidelines of PET by Medicare are published in the Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.6 – PET Scans, link: http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf
Section 220.6 – PET Scans begins on page 23 of the document and the coverage for lymphoma, which is inclusive of Hodgkin’s, is in section 220.6.5 (see page 37).
Q. What does ICD code 174.8 refer to?
A. ICD.9 diagnosis code 174.8 is part of the 174 series of codes for malignant neoplasm of the female breast. The 174 series of ICD.9 diagnosis codes is comprised of the following:
Malignant neoplasm of the female breast:
174.0 nipple and areola
174.1 central portion
174.2 upper-inner quadrant
174.3 lower-inner quadrant
174.4 upper-outer quadrant
174.5 lower-outer quadrant
174.6 axillary tail
174.8 other specified site of female breast
- ectopic sites
- inner breast
- lower breast
- malignant neoplasm of contiguous or overlapping sites of breast whose point of origin cannot be determined
- midline of breast
- outer breast
- upper breast
174.9 breast (female) unspecified
Q. Regarding F-Dopa for PET imaging, would this be a patient self-pay for the imaging agent or is there reimbursement available? Thanks for the information.
A. F-Dopa is not covered/reimbursed by Medicare. It is possible some private payers might reimburse. You would need to contact the private payers in your area for coverage and pre-authorization guidelines for this.
Q. A customer asks, Does Medicare reimburse for recurrent Cervical Cancer (restaging)? For your information, they are a NOPR-registered facility.
A. Medicare covers PET for cervical cancer for staging. The specific coverage language is:
"For the detection of metastases during the pre-treatment management phase (ie, staging) in patients with newly diagnosed and locally advanced cervical cancer with no extra-pelvic metastasis on conventional imaging tests."
PET for recurrent cervical cancer (restaging) would only be covered by Medicare if the patient is entered into the NOPR.
Q. Does the capped OPPS rate for the TC component for PET include the FDG charge?
A. No, the capped payment rates do not include reimbursement for the FDG.
Q. What is the actual reimbursement from Medicare for a PET/CT whole-body scan. I had heard PET/CT was not on the
Medicare list for cuts as of 12/25/2006.
A. In Florida, the various Medicare Part B carriers have posted on their websites the 2007 payment cap for imaging services fee schedules. For some reason the capped fee schedule posted on the Florida Medicare Part B website does not list the PET codes. All other Medicare Part B carrier websites I have looked at do list the PET codes in their payment cap fee schedules except for Florida Medicare. I cannot explain this discrepancy.
As a reference, Trailblazer Health, the Medicare Part B carrier for MD, VA, TX, DE, and D.C., has a master list of the capped fee schedules for all states posted on their website. The list of capped fee schedules is alphabetical by state. The capped fee schedule for Florida does list the capped payment amounts for the PET codes for the various fee schedule areas within Florida I would direct you to this website for the payment cap information:
http://retired.trailblazerhealth.com/tools/opplist.asp
The payment amounts posted include the geographic adjustment for each particular fee schedule area.
Q. We are currently evaluating PEM (positron emission mammography) equipment for our imaging center. Using CPT 78811 PET, Tumor, Limited what ICD-9 codes would be acceptable?
A. As I understand it, the PEM equipment is used to perform a PET scan of the chest. Therefore CPT code 78811- PET, tumor, limited would be the correct code to report this procedure. But the coverage criteria of the payor is more important than which ICD-9 codes are accepted.
The Medicare coverage of PET for breast cancer (as well as all other covered indications) can be found in the Medicare National Coverage Determinations Manual, link:
http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf
Medicare does not cover PET for diagnosis of breast cancer. Furthermore if you look at the Medicare coverage of PET for breast cancer I do not think performing a limited scan is in compliance with the coverage. One would need to perform a PET, skull base to mid-thigh or whole body to be in compliance with the spirit of the coverage. In these instances, the ICD-9 codes that support medical necessity for the Medicare coverage of PET for breast cancer are the 174 and 175 series codes.
Private payor coverage often reflects that of Medicare, but may vary. As a provider you should be able to obtain coverage and pre-authorization guidelines from the private payors in your area.
Q. Texas Medicaid fee schedule shows a reimbursement rate of just more than $100 global. Does this match what you are seeing? What do other State Medicaid programs pay? What can be done about this disservice to the children of Texas?
A. In researching this question, my sources told me that the payment rates for PET will be updated by Texas Medicaid sometime in
the February–March 2007 timeframe. So, better payments are forthcoming.
Q. I bill for 6 of our clinical PET offices. We are not a hospital setting. How will the Medicare Reimbursement affect us? And when will this take effect?
A. Beginning January 1, 2007, the Deficit Reduction Act (DRA) specifies that Medicare reimbursement for the technical component for non-hospital diagnostic imaging procedures will be reduced to the lesser of either the Hospital Outpatient Prospective Payment System (HOPPS) fee schedule or the Medicare Part B Physician Fee Schedule (MPFS) unless legislation that has been introduced in the House (HR 5704) and/or Senate (S 3795) is passed that would put a moratorium on its implementation. Assuming the DRA is implemented, the technical component reimbursement rates for PET under the MPFS would be capped at the 2007 HOPPS payment rates.
The following table summarizes the payment rates for PET scans as set forth in the 2007 HOPPS final rule:
CPT Code Description Payment 2007
78459 PET, Myocardial, metabolic evaluation $731.24
78491 PET, Myocardial perfusion single study $731.24
78492 PET, Myocardial perfusion multiple studies $731.24
78608 PET, Brain, metabolic evaluation $855.43
78811 PET, Tumor, limited $855.43
78812 PET, Tumor, skull base to mid-thigh $855.43
78813 PET, Tumor, whole body $855.43
78814 PET/CT, Tumor, limited $950.00
78815 PET/CT, Tumor, skull base to mid-thigh $950.00
78816 PET/CT, Tumor, whole body $950.00
The DRA does not impact the professional component of the MPFS, but does impact the technical component portion of the global payment. The global payment being the technical plus professional components combined.
The professional component national payment rates (note: the actual rates are adjusted slightly at the local level by a geographic adjustment) under the 2006 MPFS for the PET CPT codes you mention are as follows:
78492 = $101.57
78608 = $78.45
78813 = $106.11
The 2007 MPFS final rule calls for a 5% cut in physician reimbursement unless Congress intervenes, which they have in past years, to prevent the reduction. Additionally CMS has finalized the results of its Five Year Review of physician work values under the MPFS. They will apply a budget neutrality (BN) adjustor of .8994 to the physician work values in calculating payments for each CPT code. Accordingly the professional component national payment rates for 2007 for the codes you mention are:
78492 = $91.11
78608 = $68.33
78813 = $92.43
Now let us take a look at payment for the PET radiopharmaceuticals. Under HOPPS, as you point out, payments will continue to be paid based on the hospital’s charge for each radiopharmaceutical adjusted to cost using hospital specific overall cost-to-charge ratios (CCRs). The situation is different in the non-hospital setting under the Medicare Part B Physician Fee Schedule. Currently most Medicare Part B carriers pay separately for PET radiopharmaceuticals either off of a fee schedule amount they have set or based on invoice, depending on the carrier. For those carriers I would expect the same payment methodology for 2007. Now comes the tricky part. There are still some carriers that bundle the payment for the PET radiopharmaceuticals into the payment for the technical component (and the technical component portion of the global payment) of the PET scan CPT codes. You indicate this appears to be the case for your particular carrier. In these instances, I will be the first to tell you I do not know what those carriers will ultimately do, but it makes the most sense to me for them to unbundle the payment for the PET radiopharmaceuticals and to start making separate payment for them. We will have to wait and see how those carriers address this (assuming the DRA is implemented).
Q. As I understand it, the final rule for 2007 HOPPS has now been released at payment rates for PET technical component even less than the originally proposed amounts and the dose rate will continue to be based on cost-to-charge ratios (at least for the hospitals.) As far as I know the DRA has not been delayed. If passed, what will be the specific total reimbursement rate (technical, professional, and dose) that Independent Diagnostic Facilities can expect for CPT 78492, 78608, and 78813? In 2006 reimbursements are at a global rate. Under DRA, in 2007 the technical component will be limited to the now published amounts.
Also can you itemize or specify the professional and dose components under the proposed 2007 DRA for these respective codes (which are currently included in the global rate for IDTF)?
A. Beginning January 1, 2007, the Deficit Reduction Act (DRA) specifies that Medicare reimbursement for the technical component for non-hospital diagnostic imaging procedures will be reduced to the lesser of either the Hospital Outpatient Prospective Payment System (HOPPS) fee schedule or the Medicare Part B Physician Fee Schedule (MPFS) unless legislation that has been introduced in the House (HR 5704) and/or Senate (S 3795) is passed that would put a moratorium on its implementation. Assuming the DRA is implemented, the technical component reimbursement rates for PET under the MPFS would be capped at the 2007 HOPPS payment rates.
The following table summarizes the payment rates for PET scans as set forth in the 2007 HOPPS final rule:
CPT Code Description Payment 2007
78459 PET, Myocardial, metabolic evaluation $731.24
78491 PET, Myocardial perfusion single study $731.24
78492 PET, Myocardial perfusion multiple studies $731.24
78608 PET, Brain, metabolic evaluation $855.43
78811 PET, Tumor, limited $855.43
78812 PET, Tumor, skull base to mid-thigh $855.43
78813 PET, Tumor, whole body $855.43
78814 PET/CT, Tumor, limited $950.00
78815 PET/CT, Tumor, skull base to mid-thigh $950.00
78816 PET/CT, Tumor, whole body $950.00
The DRA does not impact the professional component of the MPFS, but does impact the technical component portion of the global payment. The global payment being the technical plus professional components combined.
The professional component national payment rates (note: the actual rates are adjusted slightly at the local level by a geographic adjustment) under the 2006 MPFS for the PET CPT codes you mention are as follows:
78492 = $101.57
78608 = $78.45
78813 = $106.11
The 2007 MPFS final rule calls for a 5% cut in physician reimbursement unless Congress intervenes, which they have in past years, to prevent the reduction. Additionally CMS has finalized the results of its Five Year Review of physician work values under the MPFS. They will apply a budget neutrality (BN) adjustor of .8994 to the physician work values in calculating payments for each CPT code. Accordingly the professional component national payment rates for 2007 for the codes you mention are:
78492 = $91.11
78608 = $68.33
78813 = $92.43
Now lets take a look at payment for the PET radiopharmaceuticals. Under HOPPS, as you point out, payments will continue to be paid based on the hospital’s charge for each radiopharmaceutical adjusted to cost using hospital specific overall cost-to-charge ratios (CCRs). The situation is different in the non-hospital setting under the Medicare Part B Physician Fee Schedule. Currently most Medicare Part B carriers pay separately for PET radiopharmaceuticals either off of a fee schedule amount they have set or based on invoice, depending on the carrier. For those carriers I would expect the same payment methodology for 2007. Now comes the tricky part. There are still some carriers that bundle the payment for the PET radiopharmaceuticals into the payment for the technical component (and the technical component portion of the global payment) of the PET scan CPT codes. You indicate this appears to be the case for your particular carrier. In these instances, I will be the first to tell you I do not know what those carriers will ultimately do, but it makes the most sense to me for them to unbundle the payment for the PET radiopharmaceuticals and to start making separate payment for them. We will have to wait and see how those carriers address this (assuming the DRA is implemented).
Q. Will the California Medical/Medicaid Program reimburse for PET/CT exams with or without TAR?
A. Medi-Cal requires a treatment authorization request (TAR) for PET and PET/CT exams. The Medi-Cal website has a document posted that lists these exams as requiring a TAR. Here is the link for reference:
http://files.medi-cal.ca.gov/pubsdoco/publications/masters-MTP/Part2/tarandnoncd7_m00i00o03.doc
Q. How do you imagine the 2007 Medicare proposed changes for payment for imaging services will affect the ability of hospitals to provide quality cancer care?
A. I think at this point in time we need to wait and see what is published in the final rule of the Medicare Hospital Outpatient Prospective Payment System for 2007. Medicare has published the proposed changes to the Hospital Outpatient Prospective Payment for 2007 and is accepting public comments through October 10, 2006. The comments will be taken under consideration by CMS and they will publish the final rule in early November.
Rather than speculate on what might happen under the proposed rule, I think it is prudent to wait until the final rule is published. At that time we will know what the payments will actually be in 2007 for PET and PET/CT scans and only then will we know what the true playing field will be for hospitals.
Q. How will the Medicare proposed changes for payment of imaging services financially impact community oncologists?
A. I think oncologists will continue to order PET scans if they think the information from PET will play a key role in a particular patient's management regardless of what the payment rates ultimately turn out to be by Medicare for 2007. If the oncologist is performing in-office PET imaging then the financial impact would be the potential reduction in the payments for the scans as discussed in the question below.
Q. How will the proposed Medicare Physician Fee Schedule for 2007 impact PET reimbursement?
A. The Medicare Physician Fee Schedule (MPFS) Proposed Rule for 2007 incorporates the mandate in the Deficit Reduction Act (DRA) that requires Medicare to pay the technical component reimbursement for non-hospital outpatient imaging at the lesser of the physician fee schedule payment or the Hospital Outpatient Prospective Payment System (HOPPS) amount for the same service. In other words the DRA caps the physician fee schedule payment for the technical component of imaging services at the HOPPS payment amount. Therefore we have to look to the HOPPS Proposed Rule for 2007 for the proposed payments for PET and this potentially would be the cap for payments under the MPFS. For 2007 under HOPPS, Medicare is proposing to pay $862.29 for all the non-myocardial PET and PET/CT CPT codes and $718.75 for all the myocardial PET CPT codes. This represents a significant reduction from where PET scan payments are in 2006 under the MPFS as the technical component payments are typically in the range of $1,800-$2,400 for non-myocardial PET and PET/CT.
It is important to note that these are "proposed" rules and are subject to possible changes when the "final" rules are published in early November. Although Medicare has the authority to alter what the payments under HOPPS for 2007 will ultimately be, only congressional legislation can change the DRA mandate as it effects payments for imaging services under the MPFS. Legislation has been introduced in the House (HR 5704) and Senate (S 3795) to provide a two year moratorium on implementation of the DRA cuts but the legislation is still pending at this time.
