UPDATES and NEWS

Article originally published in AAPC Healthcare Business Monthly March 2017

 

MEDICARE REIMBURSEMENT FOR AMYLOID PET SCANS

The Centers Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) on
September 27, 2013, which allows conditional coverage of amyloid PET under Coverage with Evidence Development (CED).
Clinical Study Approval

Study Title: Imaging Dementia—Evidence for Amyloid Scanning (IDEAS) Study
Sponsor: American College of Radiology Imaging Network
ClinicalTrials.gov Number: NCT02420756
IDEAS Study site
CMS Approval Date: 03/03/2015

 

TRANSMITTALS AND MEDICARE LEARNING NETWORK (MLN) MATTERS

Medicare Reimbursement Guidelines

A PET imaging facility may not perform an IDEAS Study PET scan until the referring physician has submitted a pre-PET clinical assessment form to the IDEAS Study database. Once the PET scan has been completed and the appropriate data uploaded to the IDEAS Study database, a system-generated notification is sent from the email address IDEAS-Study@acr.org to the PET imaging facility indicating that the case data are complete. These notifications should be maintained as documentation in the event that CMS opts to audit the PET imaging facility.

After receiving the notification, the PET facility (and the interpreting physician, if technical and professional component billing are performed separately) may submit the claim for the service to the local Medicare Administrative Contractor (MAC) or MA plan as appropriate.

2016 PET technical component reimbursement for amyloid PET imaging performed on patients enrolled in the IDEAS Study will be based on the following:

Hospital-based PET Facilities

  1. The National 2016 HOPPS payment for CPT code 78811 or 78814 (limited body PET or PET/CT, respectively) ($1,285.17 ‒ $228.37) = $1,056.80 (rates are adjusted by local wage indexes, so the exact payment will vary slightly based on region); and

 

  1. A pass-through payment for the cost of the amyloid imaging agent, calculated quarterly (generally about $3,000), depending on the specific agent administered. These rates change quarterly and are based on actual average sales price reported by the manufacturer to Medicare, plus 6%. Visit the CMS website for quarterly pass-through amounts located in the addendum B files posted for January, April, July and October of each year.

 

As noted in item 1 above, the offset for the cost of the diagnostic radiopharmaceutical attributed to APC 5594 ($228.37 for CY 2016) is deducted from the procedure, not from the pass-through amount for the drug. For hospital-based PET facilities, there is no co-payment or co-insurance assigned to pass-through drugs; there is a co-payment or co-insurance for the procedure.

 

Physician Offices and Independent Diagnostic Testing Facilities (IDTFs)

For physician offices and IDTFs, payment is determined by the Medicare Physician Fee Schedule (MPFS). The technical component payment for the procedure is carrier priced but is often capped at the HOPPS technical component rate ($1,285.17). Payment for the diagnostic radiopharmaceutical is based on the invoice cost (approximately $3,000, depending on the product used).

In the MPFS setting, all rates are subject to co-payment, co-insurance and any deductibles that the patient’s Medicare plan requires. The co-payment policies for the radiopharmaceutical differ in the MPFS setting versus the HOPPS transitional pass-through.

SPECIAL NOTICE FOR IDTF SITES ONLY
If your PET facility is an Independent Diagnostic Testing Facility (IDTF), please verify that your facility has notified your Medicare Administrative Contractor via the CMS-855B Form listing all the CPT and HCPCS level II codes used for the IDEAS Study. A list of all the potential IDEAS Study CPT/HCPCS codes as of 7-1-2016 are CPT 78811, 78814, A9586, Q9982, Q9983 and A9599.

IDTFs are required to list all CPT/HCPCS codes/procedures that they intend to perform when enrolling with the CMS-855B. If an IDTF that is already enrolled wants to perform additional CPT and HCPCS codes/procedures that were not originally specified on its CMS-855B and that are for procedure types and supervision levels similar to its previously allowed codes, the contractor shall have the IDTF amend its CMS-855B to add the additional codes and equipment listing, if necessary. A new site visit is not required. However, if the enrolled IDTF will be performing CPT or HCPCS codes for different types of procedures or with different supervision levels, a new site visit is required. Claims submitted with procedure codes not reported on the CMS-855B form and reviewed by the contractor will be denied.

Professional Component Payment

The national payment rates for the professional reading of the IDEAS study are 78811-26 $78.77 and 78814-26 $110.28.