National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Revised Information on PET Scan Coding

Note: This article was revised on August 1, 2007, to correctly list HCPCS code A4641, instead of A4691, in two places within the article and to correct one code shown in Table 2 related to physicians/practitioners billing for CPT 78491 and 78492. All other information remains the same.

Provider Types Affected
Physicians and providers who bill Medicare contractors (carriers, fiscal intermediaries (FI), and Medicare Administrative Contractors (A/B MAC)) for Positron Emission Tomography (PET) Scan services for Medicare beneficiaries

Provider Action Needed
Impact to You
Effective for services on and after January 28, 2005, your carrier, FI, or A/B MAC will deny claims for PET Scan services that contain CPT code 78609 and they will deny claims for PET Scan services on or after January 1, 2008 that contain HCPCS code A4641.

What You Need to Know
CR 5665, from which this article is taken, corrects erroneous information that was originally issued in CR 3741, transmittal 527 (New Coding for FDG PET Scans and Billing Requirements for Specific Indications of Cervical Cancer), dated April 15, 2005. CR5665 updates Medicare Claims Processing Manual, Chapter 13, Sections 60.30.1 and 60.30.2 by removing HCPCS code 78609 from the list of covered codes and HCPCS code A4641 from the list of applicable tracer codes for PET scans.

What You Need to Do
Make sure that your billing staffs are aware of these code changes and submit only covered codes in your claims for PET Scan services.

Background
The Centers for Medicare & Medicaid Services (CMS) recently learned that the Medicare Claims Processing Manual, Chapter 13 (Radiology Services), Sections 60.30.1 (Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005) and 60.30.2 (Tracer Codes Required for PET Scans), and CR 3747 (transmittal 527, dated April 15, 2005), contain incorrect information regarding CPT code 78609 (PET for brain perfusion imaging) and HCPCS code A4641.

• In Section 60.3.1, CPT code 78609 is incorrectly listed as a covered service by Medicare, and in Section 60.3.2 is incorrectly included in terms of the applicability of certain tracer codes. Similarly, Section 60.30.2 incorrectly lists HCPCS code A4641as an applicable tracer for PET Scans.

CR 5665, from which this article is taken, corrects these errors. It updates the manual by removing HCPCS code 78609 from the list of covered codes and HCPCS code A4641 from the list of applicable tracer codes for PET scans. In so doing, it also corrects correct the erroneous information that was originally issued in CR 3747.

Notes: 1) All Positron Emission Tomography (PET) Scans services (codes 78459, 78491, 78492, 78608, and 78811-78816) require the use of a radiopharmaceutical diagnostic imaging agent (tracer). Therefore, the applicable tracer code should always be used when billing for a PET scan service.
2) The correct PET Scan CPT codes and tracer HCPCS codes are listed in Tables 1 and 2, below.

Key points in CR 5665

• Effective January 28, 2005, CPT 78609 became a noncovered service for Medicare;
• Carriers, FIs, and A/B MACS will deny claims submitted with CPT code 78609 (effective January 28, 2005);
• When denying these claims, they will use:
  • Medicare Summary Notice (MSN) 16.10 “Medicare does not pay for this item or service.”
  • Claim Adjustment Reason Code 96: “Noncovered charge.”
  • Remittance Advice Remark Codes N386: —“This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp . If you do not have Web access, you may contact the contractor to request a copy of the NCD.”
• Effective January 1, 2008, HCPCS code A4641 is not an applicable tracer for PET Scans;
• You should not report HCPCS code A4641 when submitting claims for PET Scans for services on or after January 1, 2008. Instead, as of that time, when submitting claims for PET Scans containing CPT code 78491 or 78492 you should use only tracer code A9555 or A9526; and, when submitting claims for PET Scans containing CPT code 78459, 78608, or 78811-78816, you should use only tracer code A9552 (See Table 2, below).
• Carriers, FIs, and A/B MACs will not search for, and adjust, claims that have been paid prior to the implementation date, but they will adjust claims brought to their attention.

The following tables list the currently covered PET Scan CPT codes (on or after January 28, 2005) and tracer HCPCS codes, as of January 1, 2008).

Table 1

Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005

Table 2

Tracer Codes Required for PET Scans on or after January 1, 2008 (A4641 is allowed for services on or before December 31, 2007)

Additional Information
You can find more information about PET Scan codes by going to CR 5665, located at http://www.cms.hhs.gov/Transmittals/downloads/R1301CP.pdf on the CMS Web site. You will find the updated Medicare Claims Processing Manual, Chapter 13 (Radiology Services), Sections 60.30.1 (Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005) and 60.30.2 (Tracer Codes Required for PET Scans) as an attachment to that CR.

If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5665
Related Change Request (CR) #: 5665
Related CR Release Date: July 20, 2007
Effective Date: January 28, 2005 and January 1, 2008 (per article)
Related CR Transmittal #: R1301CP
Implementation Date: January 7, 2008

National Provider Identifier (NPI) News – During this testing and implementation phase for the NPI, providers should pay close attention to information from health plans and clearinghouses to understand how claims are being processed and what providers should be doing to assure no disruption in payment. Providers should also ensure that the information they are submitting on a claim is what is being transmitted to each health plan by the billing vendors or clearinghouses who may be submitting the claims on their behalf. Additional information can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.