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Medicare Transmittal 956 CR 5124 May 19, 2006 NOPR Billing Instruction Clarification – Physician Offices/IDTF use QR Modifier – Hospitals use QR and V70.7.

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Presentation on theme: "Medicare Transmittal 956 CR 5124 May 19, 2006 NOPR Billing Instruction Clarification – Physician Offices/IDTF use QR Modifier – Hospitals use QR and V70.7."— Presentation transcript:

1 Medicare Transmittal 956 CR 5124 May 19, 2006 NOPR Billing Instruction Clarification – Physician Offices/IDTF use QR Modifier – Hospitals use QR and V70.7 MLM CMS Educational Article MM5124 –Published May 31, 2006 Implemented by Medicare Contractors: June 19 th 2006 Noridian & Empire QR modifier system errors corrected! CMS Effective: January 28, 2005 NOPR Opened May 8, 2006 NOPR Patients DOS Effective: May 8, 2006

2 Timeline Providers Bill Medicare Using Appropriate Claim Form & Codes Hospitals Use UB/1450 Claim Form Technical Only Non-Hospitals Use 1500 Claim Form Professional/Technical/Global No Waiting Period Hold claims until all data entered into the Registry

3 FDG-PET Procedure and Supply Codes 2006 HCPCS Code Description Tumor imaging, positron emission tomography (PET); limited area (eg, chest, head/neck) Tumor imaging, positron emission tomography (PET); skull base to mid-thigh Tumor imaging, positron emission tomography (PET); whole body Brain imaging, positron emission tomography (PET); metabolic evaluation A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries

4 FDG-PET/CT Procedure and Supply Codes 2006 HCPCS Code Description Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (eg, chest, head/neck) Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries

5 For Carriers on 1500 Claim Form Use Modifier 2006 HCPCS Modifier Description QR Item or service provided as routine care in a Medicare specified study Modifier Use by Providers to Identify NOPR Claims Use only with procedure, not necessary with the radiopharmaceutical billed on the same DOS as the procedure.

6 Hospitals ONLY on 1450 Claim Form (UB) 2006 Hospital Revenue/ICD 9 CM Codes Description 0343 Diagnostic Radiopharmaceutical 0404 PET Procedures V70.7 Examination of participants in clinical trial V70.7 Use in the Second Diagnosis Position FL 68 From Current CMS policy CR 3741

7 A 72-year-old woman with diffuse large cell non- Hodgkin's lymphoma is undergoing chemotherapy with R-CHOP. PET/CT (skull-base to mid thigh) is requested after the second cycle of treatment for monitoring of therapy Hospital Revenue Code 2006 HCPCS/ ICD 9 CM Codes Description (QR) Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh 0343A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries N/A Other Lymphomas (malignant): Not otherwise specified (NOS) Case 1

8 Use of PET for Treatment Monitoring under NOPR One potential problem may be “collision” of NOPR intent with individual carrier frequency limits for PET studies Could lead to rejection of claim (or refusal of Medicare Advantage plan to pre-authorize study) Please notify NOPR staff is this occurs!

9 A 67-year-old man has a history of glioblastoma multiforme of left parietal lobe treated with surgery, radiation therapy, and temazolamide. Follow-up MRI demonstrates a new 8 mm focus of contrast enhancement adjacent to the original tumor bed. Brain PET is requested for restaging, to distinguish recurrent tumor for radiation necrosis Hospital Revenue Code 2006 HCPCS/ ICD 9 CM Codes Description (QR) Brain imaging, positron emission tomography (PET); metabolic evaluation 0343A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries N/A191.3 Malignant neoplasm of brain, parietal lobe Case 2

10 A 68-year-old woman has newly diagnosed dermatomyositis and progressive weight loss. CT of the chest, abdomen, and pelvis demonstrated no evidence of malignancy. Whole-body PET/CT is requested to detect an occult malignancy as the cause of her paraneoplastic syndrome Hospital Revenue Code 2006 HCPCS/ ICD 9 CM Codes Description Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body 0343A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries N/A710.3 Dermatomyositis N/A Abnormal Loss of Weight Case 3

11 Advance Beneficiary Notice (ABN) A PET facility can ask registry patients to sign an ABN. This decision is left up to each PET facility. However, an ABN should not be necessary. If patient eligibility is carefully checked before the patient is entered into the registry and before the PET scan is performed, and if the facility works closely with its referring physicians to obtain the required paperwork in a timely fashion, there should be no need for ABNs.

12 Medigap Insurance for Co-Payments Medigap insurance should cover the co-payment for a registry PET scan, as for any other Medicare covered service. Managed Medicare Plans – Medicare Advantage Managed Medicare plans such as Medicare Advantage should pay any claims that would be covered by Medicare. –Follow Pre-Authorization as required by the plan

13 Will non-Medicare insurers reimburse for patients entered in the Registry? No, there are no non-Medicare insurers who have elected to reimburse for patients entered in the registry. Patients with insurance coverage other than Medicare, including Medicaid, are not eligible to participate in the NOPR.

14 Does NOPR Apply to Inpatients? Yes. The technical charge for a PET study on a Medicare inpatient is not billed directly, but is considered to be covered by the Diagnostic Related Grouping (DRG) payment to the hospital for that patient. Inclusion of the patient in the NOPR is necessary, however, for professional component reimbursement for the PET study.


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