New 78XXX Series CPT® Codes Replace HCPCS G Codes for PET Procedures
As of April 18, 2005, the Centers for Medicare and Medicaid Services (CMS) will no longer accept the Healthcare Common Procedure Coding System (HCPCS) G codes for the reporting of positron emission tomography (PET) procedures that are covered nationally; they will be replaced with the 78XXX series CPT® codes (CMS Transmittal #527, CR 3741, April 15, 2005). The 78XXX series CPT® codes can be used to report PET retroactively to January 28, 2005.
PET claims submitted with a G code after April 18, 2005, will not be paid. Note that these dates supersede the effective date of January 1, 2005, and the implementation date of April 4, 2005, as was stated in CMS Transmittal #475, CR3726, February 11, 2005. Transmittal #518, April 8, 2005, has been rescinded.
CMS activated 11 PET CPT® codes: 3 cardiac (78459, 78491, 78492), 2 brain (78608, 78609), and 6 new tumor (78811-78816). The table below lists a crosswalk from the inactivated G codes to the new CPT®. All HCPCS Level II G codes have a status indicator "I", which is defined by CMS as, "Not valid for Medicare purposes. Medicare uses another code for the reporting of, and the payment for these codes."
|
Table 1 | ||||||
| PET CPT® Codes Effective 1/28/05 | CPT® Description of PET Procedure | Inactivated HCPCS Codes as of April 18, 2005 | Professional Component1
Status Total RVUs |
Technical Component Status |
Global
Status | |
| 78459 | Myocardial imaging, PET, metabolic evaluation | G0230 | A | 2.12 | C | C |
| 78491 | Myocardial imaging, PET, perfusion; single study at rest or stress | G0030, G0032, G0034, G0036, G0038, G0040, G0042, G0044, G0046 | A | 2.15 | C | C |
| 78492 | Myocardial imaging, PET, perfusion; multiple studies at rest and/or stress | G0031, G0033, G0035, G0037, G0039, G0041, G0043, G0045, G0047 | A | 2.68 | C | C |
| 78608 | Brain imaging, PET, metabolic evaluation | G0229, G0336 | A | 2.07 (+2.07) |
C | C |
| 78609 | Brain imaging, PET, perfusion evaluation | There are no G codes for PET imaging for brain perfusion evaluation. | A | 2.07
(+2.07) |
C | C |
| 78811 | Tumor imaging, PET, limited area (e.g., chest, head/neck) | G0125, G0219, G0210- G0218, G0220- G0228, G0253, G0254, G0296 | A | 2.18
(+.53) |
C | C |
| 78812 | Tumor imaging, PET; skull base to mid-thigh | G0125, G0219, G0210- G0218, G0220- G0228, G0253, G0254, G0296 | A | 2.70
(+.66) |
C | C |
| 78813 | Tumor imaging, PET; whole body | G0125, G0219, G0210- G0218, G0220- G0228, G0253, G0254, G0296 | A | 2.80
(+.69) |
C | C |
| 78814 | Tumor imaging, PET with concurrently acquired CT for attenuation correction and anatomical localization; limited area (e.g., chest, head/neck) | N/A | A | 3.07
(+.76) |
C | C |
| 78815 | Tumor imaging, PET with concurrently acquired CT for attenuation correction and anatomical localization; skull to mid-thigh | N/A | A | 3.39
(+.84) |
C | C |
| 78816 | Tumor imaging, PET with concurrently acquired CT for attenuation correction and anatomical localization; whole body | N/A | A | 3.47
(+.86) |
C | C |
"A" = Active status
"C" = Carrier Priced
"N/A" = Not available
1Relative Value Units (RVUs) per Pub 100-04, Medical Claims Processing, Transmittal #475, CR 3726,
February 11, 2005, First Update to the 2005 Medicare Physician Fee Schedule Database.
The following G codes are excluded (E) from payment or deleted (D) by Medicare.
|
Table 2 | ||
| Code | Status | Description |
| G0219 | E | PET imaging whole body; melanoma for non-covered indications |
| G0235 (effective 1/28/05) |
E | PET Imaging, any site, not otherwise specified (non-covered service) |
| G0252 | E | PET imaging, full/partial-ring PET scanner only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer, not covered |
| G0330 | D (effective 10/01/04) |
PET imaging, initial diagnosis cervical |
| G0331 | D (effective 10/01/04) |
PET imaging restage ovarian cancer |
"E" = service is excluded from the Medicare Physician Fee Schedule
"D" = deleted from Medicare (See Medlearn Matters # MM3750)
PET imaging codes G0219 (whole body; melanoma for noncovered indications), G0235 (any site, not otherwise specified), and G0252 (initial diagnosis of breast cancer and/or surgical planning for breast cancer) have been labeled with an "E" status indicator, indicating they are excluded from the physician fee schedule by regulation and are not covered by Medicare.
Reimbursement
As listed in the First Update to the 2005 Medicare Physician Fee Schedule (Transmittal 475, CR 3726, February 11, 2005) and as noted in Table1 above, the professional component relative value units (RVUs) for the myocardial PET studies have remained the same. However, PET brain imaging studies which were previously valued in the fee schedule as 0 now have a total professional RVU value of 2.07, and the remainder of the PET studies show an increase due to an increase in the practice expense. Note that the technical and global components continue to be carrier-priced. Carriers will establish payment amounts for the technical and global components, generally on a case-by-case basis, following review of documentation. The ACR is assisting Carrier Advisory Committee network representatives on this issue.
PET Coverage for Various Cancers and "Coverage with Evidence Development"
The Centers for Medicare and Medicaid Services (CMS) issued an update on April 1, 2005, to the National Coverage Determination (NCD) on PET for brain, cervical, ovarian, pancreatic, small-cell lung, and testicular cancers (Pub. 100-03, Transmittal 31, CR 3741). Initially, CMS implemented limited PET coverage for certain cancers; however, this PET coverage was expanded by CMS for all oncology indications with a requirement that physicians participate in and patients be enrolled in an approved clinical trial or registry. This PET NCD update clarifies the types of cancers that are covered and the clinical trials/registry enrollment requirement. All covered PET services specified in the NCD that were performed between January 28, 2005, and April 17, 2005, may be submitted retroactively as per Transmittal #527, CR 3741 (Transmittal #518 rescinded). Note that the current dates listed supersede the dates listed in Transmittal #475, CR 3726.
CMS will notify Medicare providers and beneficiaries through the Federal Registry Notice and CMS coverage Web site at www.cms.gov/coverage as more details develop and become available on PET coverage with evidence development. In addition, CMS intends to release through these venues additional clinical study/registry enrollment process information. The ACR does not anticipate that guidelines and enrollment for the PET registry will be ready until later this summer. For more details regarding the recent CMS NCD PET update, please refer to CMS Transmittal 31, CR 3741 at http://www.cms.hhs.gov/manuals/pm_trans/R31NCD.pdf
Links:
CMS Transmittal 527, CR 3741, April 15, 2005
http://www.cms.hhs.gov/manuals/pm_trans/R527CP.pdf
Transmittal 518, CR 3741, April 1, 2005 - RESINCDED
http://www.cms.hhs.gov/manuals/pm_trans/R518CP.pdf
CMS Transmittal 475, CR3726, February 11, 2005
http://www.cms.hhs.gov/manuals/pm_trans/R475CP.pdf
Federal Register Vol. 69, No. 216, November 15, 2004, p 66427
http://a257.g.akamaitech.net/7/257/2422/15nov20040800/edocket.access.gpo.gov/2004/pdf/04-24758.pdf
Society of Nuclear Medicine, PET C&R Educational Materials, March 2005
http://interactive.snm.org/index.cfm?PageID=1110&RPID=3854&FileID=19826
CMS Transmittal 402, CR 3621, December 17, 2004
http://www.cms.hhs.gov/manuals/pm_trans/R402CP.pdf
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3750.pdf
CMS Transmittal 31, CR 3741
http://www.cms.hhs.gov/manuals/pm_trans/R31NCD.pdf
Medicare National Coverage Determinations (NCD) Manual
Publication 100-03, Section 220.6
http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103c1_Part4.pdf