August 31, 2011

ACR Radiology Coding Source™ for July-August 2011 Q and A

Q: What code(s) should be reported to describe a NaF PET/CT whole body bone scan performed on a PET/CT machine to identify bone metastasis?  Will Medicare cover this procedure?

A: The appropriate CPT® code to report a sodium fluoride-18 (NaF) PET/CT whole body bone scan performed on a PET/CT scanner  to identify bone metastasis is 78816, Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body.  Additionally, the appropriate Healthcare Common Procedural Coding System (HCPCS) Level II radiopharmaceutical code A9580, Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries, must be reported. 

For Medicare reimbursement, under the Centers for Medicare and Medicaid Services (CMS) “coverage with evidence development” through the National Oncologic PET Registry (NOPR) program, the following must be included on the claim:

    ·  Appropriate PET or PET/CT CPT code for the study performed (78811-78816)    
   
·  Oncology PET modifier PI (initial treatment strategy) or PS (subsequent treatment
      strategy)
   
·  Modifier Q0 (Q zero) to identify a facility providing an investigational clinical service in a
      clinical research study
   
·  Modifier KX with modifier 26 to denote the professional component only.  Use of
      modifier KX confirms that the requirements specified in the medical policy have been
      met and allows the Medicare administrative contractor to differentiate the study as PET
      with sodium fluoride-18 (NaF) rather than PET with F-18 fluorodeoxyglucose (FDG).
      Modifier KX is not required for hospital claims, billing globally or billing only the
      technical component  
   
·  Appropriate ICD-9 cancer diagnosis code.  Hospital Outpatient Prospective Payment
      System claims must include diagnosis code V70.7 (examination of participant in
      clinical trial) in the second diagnosis position and condition code 30 (qualifying clinical
      trials non-research services provided to all patients, including managed care enrollees
      enrolled in a qualified clinical trial ) 
    ·  Radiopharmaceutical HCPCS Level II code A9580 

The NOPR program was established in response to CMS’ proposal to expand coverage for PET with F-18 FDG to include cancers and indications not currently eligible for Medicare reimbursement.  Under CMS’s “coverage with evidence development”, Medicare reimbursement can be obtained if the patient’s referring physician and provider submit data to a clinical registry managed by the NOPR to assess the impact of FDG-PET imaging on cancer management. 

Recently, CMS expanded coverage through the NOPR to include NaF-PET to identify bone metastases and improved health outcomes under “coverage with evidence development.”  The NOPR launched a registry for NaF-PET similar to the FDG-PET registry and began accepting patients on January 31, 2011. 

The NOPR is sponsored by the Academy of Molecular Imaging (AMI) and managed by the American College of Radiology (ACR) through the American College of Radiology Imaging Network (ACRIN).  

For more information on PET reporting and the NOPR, go to

www.cms.gov/transmittals/downloads/R2096CP.pdf

 www.cancerpetregistry.org/

Q: Our radiology group would like to know how long they are required to keep radiologic films in the office setting.  Are there any special rules for Medicare?

A: Currently, there is no mandate from Medicare regarding film retention in the office setting.  As part of Medicare’s Conditions of Participation (CoP), hospitals are required to retain medical records, which include radiology films, scans and other image records, as well as copies of reports and printouts for a minimum of five years.  Conversely, some States may require a longer period for maintaining medical records and radiology films.  Although Medicare’s CoP apply to hospitals, many outpatient offices and clinics follow the five-year rule unless their State requires a longer retention period.  In addition, health care facilities that perform mammograms must follow FDA regulations, which state mammography films and reports must be maintained a minimum of five years, ten years if no additional mammograms of the patient are performed at the facility, or longer if mandated by the State or local law. 

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule does not specify a record retention period.  However, HIPAA requires covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other health information for the period of time the information is maintained.

ACR members are urged to contact their State regarding radiology film and medical record retention requirements.

For more information see Hospital Conditions of Participation, medical record and radiology film retention.

Q: How should a percutaneous breast biopsy procedure be reported if a radiologist provides the guidance and the surgeon places the needle?  Should the co-surgeon modifier “62” be used?

A: No, the co-surgeon modifier “62” should not be used if a percutaneous breast biopsy procedure is performed by a surgeon and radiologist.  A percutaneous breast biopsy procedure using imaging guidance is reported with either 19102 (Breast biopsypercutaneous, needle core, using imaging guidance) or 19103 (Breast biopsy; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance) and one of the imaging guidance codes (76942, 77012, 77021, 77031, 77032).  Neither 19102 nor 19103 permits the use of a co-surgeon modifier according to the Medicare Physician Fee Schedule.  If the radiologist provides the imaging guidance and the surgeon is providing the needle placement, they should bill the codes accordingly, i.e., the radiologist bills the guidance code and the surgeon bills the needle placement code. 

The Medicare Physician Fee Schedule provides guidance on when the co-surgeon, assistant surgeon, and team surgeon codes can be used.  For codes 19102 and 19103 a modifier indicator of 0 (zero) is listed, which indicates a co-surgeon is not permitted for these procedures.