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CMS takes new position on PET codes: From G to CPT codes

Radiology Administrator's Compliance and Reimbursement Insider, May 1, 2005

By Jackie Miller, RHIA, CPC

The Medicare Physician Fee Schedule update issued February 11 contained an unexpected bonus for PET providers. CMS announced in Medicare Transmittal 475 (Change Request 3726) that it will begin to accept CPT codes for PET scans. The G codes that have plagued PET providers since Medicare began providing coverage of the modality are scheduled to be discontinued.

The PET G codes have been challenging to providers because they are defined in terms of a patient's condition rather than the type of exam. For example, a whole-body PET scan for initial staging of esophageal cancer is reported with code G0227, while a whole-body PET scan for initial staging of colorectal cancer is reported with code G0214. Further, G codes have a high level of granularity, requiring providers to differentiate between scans performed for purposes of diagnosis, initial staging, and restaging. This requires a depth of clinical history that referring physicians often do not provide.

The switch from G codes to CPT codes is effective for services performed on and after January 30, 2005. However, carriers will not be able to accept CPT codes until April 4 or later. (CMS originally indicated that CPT codes could be submitted starting April 4, but they notified the Society of Nuclear Medicine in mid-March that this date would likely be pushed back.) This means providers have a coding choice for services provided between January 30 and April 3: They can either hold claims and submit them with CPT codes when Medicare is ready to accept them, or they could have submitted the claims prior to April 4 using G codes. (CMS has confirmed that G codes would not be accepted after April 4.) Depending upon the type of scan performed, the professional component payment could increase significantly by billing with CPT codes rather than G codes.

The CPT codes that will be accepted by Medicare include the new (for 2005) codes for PET-CT scans. These codes must be used when CT and PET scans are performed simultaneously on the same scanner, but not when scans from separate machines are fused after the fact. Prior to 2005, there were no codes for concurrent PET-CT, and typically only the PET scan was billed, except in the rare situation when a separately ordered, medically necessary, full diagnostic CT exam was performed (see "Ask the Insider: Billing for PET/CT" in the March 2004 RACRI ). With the new PET-CT codes, however, providers can report the exact service that was performed.

All of these CPT codes will be activated in the Medicare Physician Fee Schedule. The professional component of the PET CPT codes will be paid on the basis of relative value units (RVU).

Depending on the mix of G codes that a radiology practice has reported, the new codes may represent a significant increase in reimbursement. Many G codes (e.g., code G0220, whole body imaging for diagnosis of lymphoma) carry professional component reimbursement of fewer than 2.10 RVUs, which is a lower number than the RVUs for any of the tumor-imaging CPT codes.

However, reimbursement for the technical component and global PET service will continue to be set by the carrier, leaving providers to depend on local Medicare contractors to make these determinations.

There is one last PET change included in Transmittal 475. Although the current G codes are being deactivated, CMS is instituting a new G code:

It appears this code is intended for use in billing Medicare for noncovered PET scans (i.e., to obtain a Medicare denial). However, CMS had not issued instructions for the code's use as RACRI went to press.

Facilities and radiology practices that bill for PET services may wish to take advantage of helpful information posted by the Society of Nuclear Medicine on its Web site (www.snm.org ), including a crosswalk between CPT codes and G codes.

Editor's note: To read Medicare Transmittal 475 (Change Request 3726), go to www.cms.hhs.gov/manuals/pm_trans/R475CP.pdf.

Jackie Miller, RHIA, CPC, senior consultant,Coding Strategies Inc., 5041 Dallas Hwy., Ste. 606, Powder Springs, GA 30127; 770/445-5566; jackie.miller@codingstrategies.com.

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