Nuclear medicine professionals will have a lot to look out for in the upcoming months regarding coding, coverage and payments for nuclear medicine procedures and products. Many of these changes become effective on January 1, 2006. Will you be ready?
Coding Changes
The electronic version of the new Current Procedural Terminology 2006 book from the American Medical Association is available for purchase and immediate download at www.ama-assn.org. Look for changes in the nuclear medicine introductory section. In this section, the CPT editorial panel approved updated and more specific language to clarify—with billers and payers—that coding and billing separately is appropriate for radiopharmaceuticals and nuclear medicine drugs, as they are not included in the nuclear medicine procedure codes. Other minor changes will occur to some obsolete procedure codes located in the hematopoietic, reticuloendothelial, and lymphatic system section. Finally, expect major changes for those of you who have been using CPT 76375 (“Coronal, sagittal, multiplanar, oblique, 3-dimensional or holographic reconstruction of CT, MRI or other tomographic modality”).
Regarding the Healthcare Common Procedural Coding System (HCPCS) level II changes for 2006: As you know, level II codes are created for many of the radiopharmaceuticals and nuclear medicine–related drugs associated with nuclear medicine procedures. Over the past 2 years, SNM’s Coding and Reimbursement Committee has worked very closely with the Centers for Medicare and Medicaid Services (CMS) HCPCS Committee to create a consistent, standard template for radiopharmaceutical HCPCS code descriptions and to modify code descriptions for radiopharmaceuticals consistent with the way you purchase and administer these unique drugs.
In June, the nuclear medicine community got a sneak peak at some of the more than 40 proposed changes to the radiopharmaceuticals during HCPCS panel open meetings. What we know is that CMS plans to create new A or J codes for all of the existing C or Q radiopharmaceutical HCPCS codes. This will allow all payers to use the same codes across the various settings. CMS also plans to change many of the current unit descriptions, such as “per vial” to “per dose,” when appropriate. CMS has also shortened the descriptions, removing some language to simplify the current code descriptions. Look for the HCPCS 2006 codes to be published by CMS on the HCPCS CMS Web site at www.cms.hhs.gov/medicare/hcpcs. Once the 2006 HCPCS is publicly available, SNM will create educational materials and post them on its Web site in the Practice Management section.
Two more coding updates became effective in October and are important for your review. First, the new and revised ICD 9 CM 2006 diagnosis codes were implemented October 1; you can obtain these codes online at www.cms.hhs.gov/medlearn/icd9code.asp. Second, CMS issued coding clarifications regarding PET radiopharmaceuticals with an implementation date of Oct. 31. If you are performing PET procedures, SNM recommends that you review the July 29 CMS Transmittal 628, change request 3945. This transmittal notes, “All PET scan services require the use of a radiopharmaceutical diagnostic imaging agent (tracer). The applicable tracer code should be billed when billing for a PET scan service. See section 60.3.2 for applicable tracer codes.” For hospitals, use HCPCS codes C1775 18F FDG per dose, Q3000 Rb-18 per dose and A9526 13N per dose. For physician offices, use A4641 for both 18F FDG per dose and Rb-82 per dose; use A9526 for 13N per dose. CMS states in this policy, “No changes are being made to the current policy. This instruction simply reflects current policy more accurately.” However, some carriers, such as TrailBlazer Health, recently changed payment policy, effective October 31. Therefore, SNM recommends that you check with your carrier regarding any potential changes arising from this recent transmittal.
Coverage
Last January, CMS announced expanded coverage for some FDG PET procedures under a new category, Coverage With Evidence Development (CED). Since then, PET facilities have been anxiously waiting more details from CMS regarding a “high-quality PET registry.” In February, the Academy of Molecular Imaging and the American College of Radiology Imaging Network partnered with CMS to make this new coverage option a reality for PET facilities. SNM, the American Society of Clinical Oncologists, and the American College of Radiology are participating as advisory organizations on this PET registry project. Information about the new National Oncologic PET Registry (NOPR) is available on the ACRIN Web site at www.acrin.org. Providers can sign up for the PET registry broadcast list by contacting pet_registry{at}phila.acr.org.
The National Oncologic PET Registry is progressing well; CMS has approved the final case forms and data collection process that were submitted for review in late March. ACRIN has begun work on creating the Web-based forms and on implementing the administrative processes for managing the project. Before the PET data registry’s implementation, CMS must finalize details related to data confidentiality and ownership. Once they are finalized, CMS intends to publish detailed information and instructions later this fall. PET providers will find this information—when published by CMS—on its coverage page under the General Information section at www.cms.hhs.gov/coverage. Additionally, due to the lapse in time since the January transmittal, a CMS official told SNM that “the agency intends to publish a new transmittal” at www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp.
Medicare Payment Systems
Starting January 1, 2006, Medicare will offer a new “Prescription Drug Coverage” under a designation called Part D. It will cover some limited brand and generic drugs. This new drug coverage requires all people with Medicare to make a decision about their coverage. As a medical professional, your Medicare patients may ask you questions about this. Specifically, they may ask if this new Part D coverage applies to any of the drugs or radiopharmaceuticals that you will administer during their nuclear medicine procedure. The simple answer is “no.” The drugs and radiopharmaceuticals provided with nuclear medicine procedures are covered under Part A or Part B services for Medicare patients, not under the new Part D coverage.
CMS issued a Medlearn Matters article, number SE0557, that clarifies this issue. In it, CMS states, “There has been some confusion among fee-for-service (FFS) providers regarding their ability to bill drugs covered under Part D. In short, being an enrolled provider in the FFS does not impart Part D-related billing privileges. Medicare Part B covers a limited number of prescription drugs and biologicals. These drugs continue to be covered and paid for under the FFS Medicare program, and FFS providers will continue to bill their carriers, fiscal intermediaries and durable medical equipment regional carriers (DMERCs) for these drugs.”
CMS has prepared a toolkit for health care professionals at www.cms.hhs.gov/medlearn/provtoolkit.pdf, should you wish to learn more about the Part D service. You can also provide your patients with the CMS phone number, 800-MEDCARE (633–4227), or direct them to www.medicare.gov for more answers to their questions.
Physician Fee Schedule and HOPPS Comments
This summer, CMS published proposed 2006 payment policy rules for both the physician fee schedule (PFS) and the hospital outpatient payment system (HOPPS). These proposed rules can be reviewed on SNM’s Web site under the Practice Management section. SNM provided CMS with detailed comments to both rules; those comments are also located on the SNM Web site. CMS will implement both CMS rules on January 1, 2006. PFS will be posted at www.cms.hhs.gov/physicians/pfs/default.asp; HOPPS will be posted at www.cms.hhs.gov/providers/hopps/fr2006.asp. As JNMT goes to press, these finalized 2006 rules are not available. SNM cannot predict which policies will be finalized or modified. Please check the SNM or CMS Web site for the most up-to-date final CMS published payment policies and rates.