Coding UPDATE: PET Providers Should Hold Claims Beginning April 4, 2005

April 4, 2005

Coding UPDATE: PET Providers Should Hold Claims Beginning April 4, 2005

The coding change planned for PET procedures will not take place exactly as scheduled (see original story in the Related Items box below). Although many of the G-codes will be discontinued in Medicare systems on schedule, the planned implementation and coding instructions for PET CPT codes will be delayed, resulting in a time period during which providers are advised to hold claims until instructions can be issued.

The SNM and other professional societies were contacted by a Medicare & Medicaid Services (CMS) official requesting our assistance in communicating this important coding and payment information to both hospital and nonhospital PET providers. The CMS official stated, “G-codes (for PET procedures) should not be used after April 4; those claims will not be paid. In the interim, providers should hold claims and wait for communication from their Carriers or Fiscal Intermediaries…. CMS plans to notify contractors of this issue.”

SNM received this information as a result of the good working relationship developed between SNM and CMS officials. Denise Merlino, SNM coding advisor, stated, “We continue to work closely with CMS officials and are confident that they are aware of how important it is that our members get timely and accurate coding information.” CMS is holding emergency meetings to reach a resolution promptly and provide coding clarification to minimize the time required for providers to hold PET claims.

Several claims processing publications released over the past few months by CMS indicated CMS would activate and adopt CPT codes for PET procedures and discontinue many of the previously used G series HCPCS codes. For physician providers and critical access hospitals, this coding change was to be implemented April 4, retroactive to Jan. 1 or 30th respectively. (See Related Items box below for links to the relevant CMS transmittals.) At present CMS has provided no instructions to hospitals paid under OPPS nor have they released their coding and coverage guidance regarding the use of PET and PET/CT codes or the instructions for the implementation of the PET data registry.

Essentially, these instructions would have activated three cardiac, two brain, and six (new this year) tumor PET CPT codes for Medicare and other patients covered by CMS programs. Due to several constraints not identified by CMS, the CMS official stated, “CMS currently is unable to issue our instructions to carriers regarding the registry or the new PET CPT coding.” The SNM strongly recommends that PET providers contact their Carrier or Fiscal Intermediaries regarding coding for PET procedures in April.

Also in the Related Items box below you will find the “SNM PET to HCPCS Level II Crosswalk,” a summary of the deactivated G-codes linked to the PET CPT codes to assist SNM members.

PET: CPT to HCPCS Level II Crosswalk (Updated 04/1/2005)