Medicare Claims Hold on FDG PET for Solid Tumors Extended Until November 30, 2014

On October 3, 2014 we reported that Medicare announced a temporary processing freeze on claims for FDG PET scans for solid tumors.  Medicare originally announced that claims submitted between October 6th and November 10th were to be held while they updated and tested their claims processing systems.  Processing was to begin again on November 11th.  Medicare has now extended the hold on these claims until November 30th.

CMS claims the freeze is necessary so that they can implement the PET claims edits that it announced last spring.  Under the National Coverage Determination (NCD) for FDG PET for solid tumors, Medicare will pay for up to 3 subsequent treatment strategy scans per cancer.  Local Medicare contractors may pay for additional scans if they are deemed medically necessary.

Break Away from the Static

In Transmittal 2932, CMS announced it was creating two new claims edits to implement this policy.  One of the edits will apply when a single claim contains more than 3 subsequent treatment strategy scans for the same cancer diagnosis.  The other edit will apply when the number of subsequent treatment strategy scans on the current claim, added to the subsequent treatment strategy scans in the patient’s claims history, exceeds the maximum of three for the same cancer diagnosis.

In either case, the Medicare contractor will deny the claim for the 4th or subsequent scan unless the provider applies modifier.  The provider can apply modifier KX to the additional scan if “the requirements specified in the MACs’ medical policy have been met.”

ADVOCATE will continue to provide updates as information becomes available.

Best Regards,
Kirk Reinitz, CPA