Claims for PET scan services must be billed on Form-CMS 1500 or the electronic equivalent with the appropriate HCPCS or Procedure code and diagnosis codes to the local carrier. Effective for claims received on or after July 1, 2001, PET modifiers were discontinued and are no longer a claims processing requirement for PET scan claims. Therefore, July 1, 2001, and after the MSN messages regarding the use of PET modifiers can be discontinued. The type of service (TOS) for the new PET scan procedure codes is TOS 4, Diagnostic Radiology. Payment is based on the Medicare Physician Fee Schedule.
B. Billing and Payment Instructions or Responsibilities for FIs
Claims for PET scan procedures must be billed to the FI on Form CMS-1450 (UB-92) or the electronic equivalent with the appropriate diagnosis and HCPCS “G” code or Procedure code to indicate the conditions under which a PET scan was done. These codes represent the technical component costs associated with these procedures when furnished to hospital and SNF outpatients. They are paid as follows:
• under OPPS for hospitals subject to OPPS
• under current payment methodologies for hospitals not subject to OPPS
• on a reasonable cost basis for critical access hospitals.
• on a reasonable cost basis for skilled nursing facilities.
Institutional providers bill these codes under Revenue Code 0404 (PET Scan).
Medicare contractors shall pay claims submitted for services provided by a critical access hospital (CAH) as follows: Method I technical services are paid at 101% of reasonable cost; Method II technical services are paid at 101% of reasonable cost, and professional services are paid at 115% of the Medicare Physician Fee Schedule Data Base.
In the absence of national frequency limitations, for all indications covered on and after July 1, 2001, contractors can, if necessary, develop frequency limitations on any or all covered PET scan services.
D. Post-Payment Review for PET Scans
As with any claim, but particularly in view of the limitations on this coverage, Medicare may decide to conduct post-payment reviews to determine that the use of PET scans is consistent with coverage instructions. Pet scanning facilities must keep patient record information on file for each Medicare patient for whom a PET scan claim is made. These medical records can be used in any post-payment reviews and must include the information necessary to substantiate the need for the PET scan. These records must include standard information (e.g., age, sex, and height) along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed. Such information must include, but is not limited to, the date, place and results of previous diagnostic tests (e.g., cytopathology and surgical pathology reports, CT), as well as the results and reports of the PET scan(s) performed at the center. If available, such records should include the prognosis derived from the PET scan, together with information regarding the physician or institution to which the patient proceeded following the scan for treatment or evaluation. The ordering physician is responsible for forwarding appropriate clinical data to the PET scan facility.