• E-mail
• Print
• PDF

Setting up a solid PET/CT program takes planning and forethought

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

Adding new technology can help you bring in new customers and additional revenue. But if you don't move carefully, it can also cause major headaches and unanticipated problems.

When Moncrief Cancer Center in Fort Worth, TX, decided to add PET/CT, it established a task force that meets weekly to discuss the project, according to Ed Townley, the manager of patient financial services.

The group, led by the center's information technology director, considered several points before it began, said Townley:

The first step toward adding a PET/CT program involves determining whether you have the patient volume to support one. Consider the following:

Finding the answers to these questions is critical, said Townley.

Also consider your competition-or potential competition. "Keep in mind that you will have competition," said Townley. "It's only just a matter of when."

Then ask yourself these questions:

After you decide that you are going to move ahead in the process to add PET/CT, consider the physical site. Make sure it meets your needs:

Plan ahead, because it's not easy to make changes later on if you find the site is insufficient, said Townley.

It's also important to plan ahead when it comes to billing to ensure that you can collect on your investment. Examine your contracts and verify that they will allow you to add new services in the middle of a contract period. Moncrief had many contracts that were a mix of annual and two-year agreements. Most pacts allowed for adding the new services as an addendum, but others were insistent that new services not be added until the end of the contract period, when it was up for negotiation, Townley said.

Moncrief also had to settle with carriers what codes they would use. "We had some carriers that were not enthusiastic about adding G-codes," said Townley. At that time there was only one code for PET-CPT Code 78810. "They weren't interested in HCPCS codes at all." However, other carriers were interested in the HCPCS codes because they provided a higher level of specificity, Townley recalled. Once some of the carriers understood the level of specificity, they approved the use of the G-codes.

Since Moncrief began its PET/CT program, CPT codes have been added for use with PET (although the timeline for use of these codes is still uncertain). "We're trying to ensure that [the payers will] accept the new CPT codes, and we're still in negotiations with them about that, said Townley.

Because different carriers have different preferences, it was critical for Moncrief to set up billing systems that recognized those differences, said Townley. For example, one carrier wanted them to use CPT code 78810, which did not include the cost for FDG. (FDG is the radioactive sugar that makes the scan work.) That was an additional cost, according to the billing codes. Other carriers, however, allowed them to use the G-code, which included the FDG dose. "We had to set up our procedures a little bit differently to flag that FDG dose as a separate line item on the charge," said Townley.

Be proactive when working with Medicare. "If you have a new technology coming, get in touch with your local Medicare carrier to let it know it's coming and discuss it. If they understand the technology they are less likely to deny first and pay on appeal," says Townley.

Townley said the problems didn't end even though the coding issues were settled. Some carriers neither had the codes to existing contracts nor made them billable by the time the PET/CT machine was ready for use. The contracts failed to specify a timeline for this process, which left Moncrief at the mercy of the carriers.

"We were open, and had fixed expenses," said Townley, but they could only see patients with certain carriers. Fortunately for Moncrief, the physicians who were referring patients for the new PET/CT scans understood the problem and helped by sending patients who could be processed, Townley said. There were times when patients had to be rescheduled because of delays in precertification, but they tried to avoid this whenever possible.

Insider says: To avoid problems with carriers, make changes to your contracts now to ensure that you can add technology in the future. Specifically, add a paragraph in your contracts that limits the length of time a carrier has from when the contract is signed to when all codes are uploaded into the system and approved for billing (e.g., 30 days), said Townley. Also be certain that the contract explicitly states that those same time limits apply to any outside precertification firm that the carrier uses.

Once your PET/CT operation is up and running, set up a plan to flag diagnoses that will be problematic from a billing standpoint and those that will require additional supporting documentation. Townley has written up checklists for areas about which Medicare is particular to ensure that all necessary information is collected to support reimbursement requests.

"We have a state Medicaid carrier that will not pay for PET or PET/CT under any circumstances," said Townley. Some versions of TRICARE will also deny reimbursement for these scans, he added. "You need to let your scheduler know which [insurance] carriers are problematic [so that they can] let you know when a patient with one of these carriers is in the pipeline."

In addition to taking steps to ensure that the procedures you perform will be covered, decide ahead of time what you will do if something is not covered, said Townley.

It's a good idea to separate employees handling scheduling and precertification. It is too difficult to have the scheduler handle precertifications, said Townley. He or she probably won't have time to sit on the phone and wait for an answer on a case.

Also ensure that appropriate staff members review appointments to prevent denials, said Townley.

"At our facility, the reading radiologist reviews for medical necessity and makes certain the scan will give the referring physician the information he or she needs," said Townley. A coder also looks at the information to assign the proper diagnosis and procedure codes.

Having both the radiologist and coder review the information at the same time can flag potential problem areas, such as whether additional pathology or clinical information is needed to justify the scan.

"We do a lot of work on the front end and, as a result, we've never had a denial in a year or more of operation," said Townley.

Insider says: Medicare now conducts post-payment reviews with PET scans. This means you must collect all the documents you need to substantiate medical necessity at the time of the exam, said Stacie L. Buck, RHIA, LHRM. Trying to get that information later will prove problematic, she predicted. When you receive this information, keep it accessible with other medical records for the patient, she said. A documentation checklist is helpful in this process.

Although it's important to establish solid systems up-front, remain flexible.

"Whatever process you put in place out in the trenches, you will find that it changes," Townley said. "If you have any process or procedure in place at the beginning of your program, don't think it will be equally valid eight months or a year down the line. My suggestion would be to reevaluate regularly. Come back after three months and examine everything from the top down."

Editor's note: Townley and Buck spoke during a recent audioconference, "PET/CT: Strategies for setting up an effective program," sponsored by HCPro, Inc., the company that publishes RACRI. To order a copy of the tape, call our Customer Service Department at 800/650-6787.

Insider sources

Ed Townley, manager of patient financial services at Moncrief Cancer Center in Fort Worth, TX.

Stacie Buck, RHIA, LHRM, president of Health Information Management Associates, Inc., in North Palm Beach, FL

• E-mail to a Colleague
• Print