Medicare PET Scans Payment Delay Announced

Medicare has announced a temporary processing freeze on claims for FDG PET scans for solid tumors.  Claims submitted between October 6th and November 10th will be held while CMS updates and tests its claims processing systems.  Processing will begin again on November 11th.  Medicare states that the freeze applies to “claims containing Healthcare Common Procedure Coding System (HCPCS) A9552 for all oncologic conditions.”

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.

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.

Break Away from the Static

In either case, the Medicare contractor will deny the claim for the 4th or subsequent scan unless the provider applies modifier KX (Requirements specified in the medical policy have been met).  As explained in Transmittal 2932, the provider can apply modifier KX to the additional scan if “the requirements specified in the MACs’ medical policy have been met.”

Keep in mind that Medicare does not cover scans performed to monitor tumor response during treatment when no change in therapy is contemplated, or when the scan is performed for surveillance purposes after completed treatment.  These types of scans should not be submitted with modifier KX.

As more information becomes available, ADVOCATE will continue to keep you up to date.

Best regards,
Jeffrey Voytko, CPA
Practice Manager