Wednesday, November 18, 2015

NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions (A49325)


Coverage indications and limitations, including nationally non-covered conditions (e.g., the use of FDG PET imaging to determine initial treatment strategy in patients with adenocarcinoma of the prostate), are described within the IOM sections referenced above. The NCD includes a chart, which summarizes coverage, and non-coverage for initial and subsequent treatment strategies for FDG PET (see below). Please note, however, that the ICD-9-CM diagnosis code, as always, is only one piece of information in support of the medical necessity of the service. All requirements must be met, and the clinical documentation in the medical record must support all of the requirements.

Effective for dates of service on and after June 11, 2013 Medicare will cover three FDG PET scans following initial (-PI modifier) Anti-cancer treatment to guide subsequent (-PS modifier) management. The scans must be for the same cancer diagnosis. When reporting the subsequent FDG PET scans the -PS modifier should be appended. Any subsequent (-PS modifier) FDG PET scan beyond the third scan will also require the use of the -KX modifier. Please append a -KX modifier, in tandem with medical necessity documentation in the patient record, whenever there is a justifiable need to order additional PET scans beyond three allowable PET scans for the same cancer diagnosis.

FDG PET Coverage for Oncologic conditions:
Tumor Type Initial Treatment Strategy Subsequent Treatment Strategy
Colorectal Cover Cover
Esophagus Cover Cover
Head & Neck (not Thyroid CNS) Cover Cover
Lymphoma Cover Cover
Non-Small Cell Lung Cover Cover
Ovary Cover Cover
Brain Cover Cover
Cervix Cover w/exception* Cover
Small Cell Lung Cover Cover
Soft Tissue Sarcoma Cover Cover
Pancreas Cover Cover
Testes Cover Cover
Breast (female and male) Cover w/exception* Cover
Melanoma Cover w/exception* Cover
Prostate Non-Cover Cover
Thyroid Cover Cover
All Other Solid Tumors Cover Cover
Myeloma Cover Cover
All other cancers not listed herein Cover Cover


*Cervix: Non-covered for the initial diagnosis of cervical cancer related to initial treatment strategy. All other indications for initial treatment strategy are covered.

*Breast: Non-covered for initial diagnosis and/or staging of axillary lymph nodes. Covered for initial staging of metastatic disease. All other indications for initial treatment strategy are covered.

*Melanoma: Non-covered for initial staging of regional lymph nodes. All other indications for initial treatment strategy are covered.

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