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Medicare Transmittal 956 CR 5124
May 19, 2006
•
NOPR Billing Instruction Clarification
– Physician Offices/IDTF use QR Modifier
– Hospitals use QR and V70.7
•
MLM CMS Educational Article MM5124
– Published May 31, 2006
CMS Effective: January 28, 2005
NOPR Opened May 8, 2006
NOPR Patients DOS Effective: May 8, 2006
Implemented by Medicare Contractors:
June 19th 2006
Noridian & Empire QR modifier system errors corrected!
Timeline
Hold claims until
all data entered
into the Registry
No Waiting Period
Providers Bill Medicare
Using Appropriate
Claim Form & Codes
Hospitals Use
UB/1450 Claim Form
Technical Only
Non-Hospitals Use
1500 Claim Form
Professional/Technical/Global
FDG-PET Procedure and Supply Codes
2006
Description
HCPCS
Code
78811
Tumor imaging, positron emission tomography (PET);
limited area (eg, chest, head/neck)
78812
Tumor imaging, positron emission tomography (PET);
skull base to mid-thigh
78813
Tumor imaging, positron emission tomography (PET);
whole body
78608
Brain imaging, positron emission tomography (PET);
metabolic evaluation
A9552
Fluorodeoxyglucose F-18 FDG, diagnostic,
per study dose, up to 45 millicuries
FDG-PET/CT Procedure and Supply Codes
2006
Description
HCPCS
Code
78814
Tumor imaging, positron emission tomography (PET) with
concurrently acquired computed tomography (CT) for attenuation
correction and anatomical localization;
limited area (eg, chest, head/neck)
78815
Tumor imaging, positron emission tomography (PET) with
concurrently acquired computed tomography (CT) for attenuation
correction and anatomical localization; skull base to mid-thigh
78816
Tumor imaging, positron emission tomography (PET) with
concurrently acquired computed tomography (CT) for attenuation
correction and anatomical localization; whole body
A9552
Fluorodeoxyglucose F-18 FDG, diagnostic,
per study dose, up to 45 millicuries
For Carriers on 1500 Claim Form Use Modifier
2006
HCPCS
Modifier
QR
Description
Item or service provided as routine care in a Medicare specified
study
Modifier Use by Providers to Identify NOPR Claims
Use only with procedure, not necessary with the radiopharmaceutical billed on the
same DOS as the procedure.
Hospitals ONLY on 1450 Claim Form (UB)
2006
Description
Hospital
Revenue/ICD 9 CM
Codes
0343
Diagnostic Radiopharmaceutical
0404
PET Procedures
V70.7
Examination of participants in clinical trial
V70.7 Use in the Second Diagnosis Position FL 68
From Current CMS policy CR 3741
Case 1
A 72-year-old woman with diffuse large cell nonHodgkin's lymphoma is undergoing chemotherapy
with R-CHOP. PET/CT (skull-base to mid thigh) is
requested after the second cycle of treatment for
monitoring of therapy.
2006
Hospital
Revenue
Code
2006
HCPCS/
ICD 9 CM
Codes
Description
0404
78815
(QR)
Tumor imaging, positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation correction and
anatomical localization; skull base to mid-thigh
0343
A9552
Fluorodeoxyglucose F-18 FDG, diagnostic,
per study dose, up to 45 millicuries
N/A
202.80
Other Lymphomas (malignant): Not otherwise specified (NOS)
Use of PET for Treatment Monitoring under NOPR
• One potential problem may be “collision” of NOPR
intent with individual carrier frequency limits for PET
studies
• Could lead to rejection of claim (or refusal of Medicare
Advantage plan to pre-authorize study)
• Please notify NOPR staff is this occurs!
Case 2
A 67-year-old man has a history of glioblastoma multiforme of
left parietal lobe treated with surgery, radiation therapy, and
temazolamide. Follow-up MRI demonstrates a new 8 mm focus
of contrast enhancement adjacent to the original tumor bed.
Brain PET is requested for restaging, to distinguish recurrent
tumor for radiation necrosis.
2006
Hospital
Revenue
Code
2006
HCPCS/
ICD 9 CM
Codes
Description
0404
78608
(QR)
Brain imaging, positron emission tomography (PET);
metabolic evaluation
0343
A9552
Fluorodeoxyglucose F-18 FDG, diagnostic,
per study dose, up to 45 millicuries
N/A
191.3
Malignant neoplasm of brain, parietal lobe
Case 3
A 68-year-old woman has newly diagnosed dermatomyositis
and progressive weight loss. CT of the chest, abdomen, and
pelvis demonstrated no evidence of malignancy. Whole-body
PET/CT is requested to detect an occult malignancy as the
cause of her paraneoplastic syndrome.
2006
Hospital
Revenue
Code
2006
HCPCS/
ICD 9 CM
Codes
Description
0404
78816
Tumor imaging, positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation correction and
anatomical localization; whole body
0343
A9552
Fluorodeoxyglucose F-18 FDG, diagnostic,
per study dose, up to 45 millicuries
N/A
710.3
Dermatomyositis
N/A
783.21
Abnormal Loss of Weight
Advance Beneficiary Notice (ABN)
• A PET facility can ask registry patients to sign an
ABN. This decision is left up to each PET facility.
However, an ABN should not be necessary. If patient
eligibility is carefully checked before the patient is
entered into the registry and before the PET scan is
performed, and if the facility works closely with its
referring physicians to obtain the required paperwork
in a timely fashion, there should be no need for ABNs.
Medigap Insurance for Co-Payments
• Medigap insurance should cover the co-payment for a
registry PET scan, as for any other Medicare covered
service.
Managed Medicare Plans – Medicare Advantage
• Managed Medicare plans such as Medicare
Advantage should pay any claims that would be
covered by Medicare.
– Follow Pre-Authorization as required by the plan
Will non-Medicare insurers reimburse for patients
entered in the Registry?
• No, there are no non-Medicare insurers who have
elected to reimburse for patients entered in the
registry. Patients with insurance coverage other than
Medicare, including Medicaid, are not eligible to
participate in the NOPR.
Does NOPR Apply to Inpatients?
• Yes.
• The technical charge for a PET study on a Medicare
inpatient is not billed directly, but is considered to be
covered by the Diagnostic Related Grouping (DRG)
payment to the hospital for that patient.
• Inclusion of the patient in the NOPR is necessary,
however, for professional component reimbursement
for the PET study.