September 30, 2009
CMS has issued revised instructions for implementing National Coverage of FDG PET for Solid Tumors and Myeloma. This change request rescinds and replaces transmittal 1772, CR 6464, dated July 17, 2009. The following summarizes the revisions. Complete Instruction Manual
Subject: FDG PET for Solid Tumors and Myeloma
Summary of Changes: CMS is adopting a coverage framework that replaces the four-part diagnosis, staging, restaging and monitoring response to treatment categories with a two-part framework that differentiates FDG PET imaging used to inform the initial antitumor treatment strategy from other uses related to guiding subsequent antitumor treatment strategies after the completion of initial treatment. CMS is making this change for all NCDs that address coverage of FDG PET for all oncologic conditions.
Effective date: April 6, 2009
Implementation date: October 19, 2009
Some of the specific changes include:
- Definition Changes
- Effective for services on or after April 6, 2009, the terms “diagnosis” and “staging” will be replaced with “Initial Treatment Strategy.”
- Effective for services on or after April 6, 2009, the terms “restaging” and “monitoring” will be replaced with “Subsequent Treatment Strategy.”
- Billing and Coverage Changes for PET Scans Effective for Services on or After April 6, 2009
- Effective for services on or after April 6, 2009, Medicare will not cover the use of FDG PET imaging to determine initial treatment strategy in patients with adenocarcinoma of the prostate.
- Medicare will also not cover FDG PET imaging for subsequent treatment strategy for tumor types other than breast, cervical, colorectal, esophagus, head and neck (non-CNS/thyroid), lymphoma, melanoma, myeloma, non-small cell lung, ovarian, and thyroid, unless the FDG PET is provided under the coverage with evidence development (CED) paradigm (billed with modifier -Q0, see section 60.15).
- Medicare will cover FDG PET imaging for initial treatment strategy for myeloma.
- Other Changes Include:
- New modifiers for PET scans
- Billing Changes for A/B MACs, FIs and Carriers
- Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes.
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