Medicare PET/CT Reimbursement for Oncology: What’s covered, what’s notPosted on: 08.16.18
PET/CT is a vital diagnostic imaging tool and is especially effective in revealing conditions such as cancer and brain disorders. When it comes to Medicare coverage, there are a number of misconceptions about PET/CT reimbursements.
In the majority of cases, PET/CT imaging is covered when clinically necessary, either as an initial treatment strategy or a subsequent treatment strategy.
Few exceptions apply to specific breast and cervical cancer, and melanoma diagnoses. The initial treatment of prostate cancer is the only non-covered event. Below is a consolidated reference chart that details PET/CT insurance reimbursement for specific conditions.
|Tumor Type||Initial Treatment Strategy||Subsequent Treatment Strategy|
|Breast Cancer (female & male)||*CWE||✓|
|Head & Neck Cancer (not thyroid or CNS)||✓||✓|
|Non-Small Cell Lung Cancer||✓||✓|
|Small Cell Lung Cancer||✓||✓|
|Soft Tissue Sarcoma||✓||✓|
|All other solid tumors||✓||✓|
|All other cancers not listed||✓||✓|
*CWE = Covered w/ exceptions
Cervical: Nationally non-covered for the diagnosis of cervical cancer related to initial anti-tumor treatment strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are nationally covered.
Breast: Nationally non-covered for initial diagnosis and/or initial staging of axillary lymph nodes. Nationally covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for breast cancer are nationally covered.
Melanoma: Non-covered for initial staging of regional lymph nodes. All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.
Leukemia: Nationally covered under “all other cancers not listed.”
Prostate cancer (dx 185.0) is not covered for initial treatment strategy. Therefore, all PI modifiers for 185.0 would be denied and PS modifiers would follow the same frequency as other cancer diagnosis codes.
Smart ways to take advantage of the ASNC ImageGuide RegistryPosted on: 01.18.18
Launched in 2015, the ASNC ImageGuide Registry is the first national registry developed to support non-invasive cardiac imaging and reduce the increasing regulatory reporting burden. It effectively promotes and ensures continuous quality improvement for referring physicians, technologists, and laboratories by improving efficiency, elevating the level of patient care, and reducing downstream costs. With equal weight, it was designed with the desire to build a database that spurs new research that will, in turn, grow and expand the nuclear cardiology field.
Why is it important to physicians?
Across the entire healthcare insurance industry, plan payers are continuously moving toward value-based purchasing where cost and quality are major factors that help determine reimbursement levels. Alternative payment models, bundled payments, and higher deductible plans in the commercial insurance market and Medicare’s new quality payment and the MACRA MIPS programs are clear indications of the shift in direction. All lend themselves to physicians practicing within the clinical practice guidelines. The ImageGuide Registry can promote and reinforce the highest quality delivery of care and improve outcomes at an appropriate cost point, which, in turn, can help increase reimbursements.
In addition, the measures, which were created by and for ASNC members, are more meaningful to the nuclear cardiology industry than what would be reported through traditional MIPS measures, another way ASNC has committed to helping physicians achieve appropriate reimbursements and promoting the highest level of excellence in diagnostic imaging.
What are the benefits?
The ImageGuide registry allows physicians to submit data and, based on ASNC reporting guidelines, determine their level of performance. Are they testing the proper patients with the appropriate indications and using the applicable protocols? Are they using dose optimization strategies and returning reports to referring physicians on a timely basis? Physicians, or the practice administrator, can review the data over a given time period and identify areas for improvement.
Given the change in healthcare reform and the increase in out of pocket costs, patients are becoming more savvy. As consumers, they want to make sure they choose a physician that delivers the highest quality service, orders only the appropriate tests, and helps them avoid multiple copayments for unnecessary visits. The registry offers concrete evidence that helps physicians demonstrate the value they provide to patients who are paying more than they have in years passed.
Physicians will be able to use the registry to compare their performance against the 15 different metrics it tracks. And, because CMS has recognized ASNC’s ImageGuide Registry as a Qualified Clinical Data Registry (QCDR), physicians who participate and submit data to the registry will also meet the Physician Quality Reporting System (PQRS) requirements each year.
How do physicians submit data?
Data can be quickly and easily submitted manually through the register’s portal, which takes a speedy 60-90 seconds. If offices are using reporting software, like Sytermed, Cedars-Sinai, or INVIA, they’ll be able to automatically submit their data and bypass the manual entry.
ASNC asks that physicians submit their tests on a regular basis, without any cherry picking of cases. The objective is to review all tests to identify opportunities for improvement. Physicians will be able to view their individual data, but the practice administrator will be able to look a comprehensive report of the entire lab’s performance. Even though it’s physicians who are being tracked, it’s also helpful for the technologists because the registry tracks overall quality. It takes a whole team to improve the quality of service and care, so the reporting applies to the entire lab.
Who should join the ASNC Registry?
The registry is available to any nuclear cardiology lab or physician. In fact, for cardiologists who perform nuclear cardiology, participation in MIPS through ImageGuide is the most cost-efficient and effective method of submitting data. Because the benefit from Medicare applies to total Medicare receivables, and ImageGuide is specific to nuclear cardiology, physicians are able to track their imaging, improve it, and reap the benefits without having to submit as much data. Other registries often require the submission of all patient management.
Practices can be set up in the registry as a cardiac imaging group, a smaller practice, or simply as physicians performing nuclear cardiology. If you’re an ASNC member, the registry is complimentary with your paid membership. If you’re not a current member, the cost is $750 per year, which is still a prudent investment given the potential reduction in Medicare reimbursements it could help avoid.
An easy transition
If you think that participation in the registry will require heavy lifting, it’s quite the opposite. ASNC has support that can help will registration and data submission, initially and ongoing, so it’s not as difficult as one would think. If you’d like to get started, simply visit the ImageGuide portal and begin the enrollment process. If you have questions or need assistance, contact an ASNC representative.