- Outpatient Services for Registered Inpatients
- Using the IVR to Avoid Eligibility and Entitlement-Related Claim Rejections and RTPs
- Allergen Immunotherapy Preparation (95144-95165)
- Ambulatory Surgical Center Approved HCPCS Codes and Payment Rates
- Annual Wellness Visits ‑ Billing Tips for Physicians
- Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)
- Billing for Services Not Included in the FQHC Benefit
- Attention all OPPS Providers: Provider-Based Department Edits Being Implemented on/after 8/1/2023
- Billing Medicare for a Denial - Condition Code 21
- URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
- Billing Medicare Part A When VA-Eligible Medicare Beneficiaries Receive Services in Non VA Facilities
- Condition Code G0 Reminder
- CPT Code 15830: Excision, Excess Skin and Subcutaneous Tissue; Abdomen, Infraumbilical Panniculectomy
- Electronically Submitted Claims that Exceed $99,999.99
- ESRD Facilities: Clarification for Providing Dialysis Services to Patients Acute Kidney Injury
- Federally Qualified Health Centers Behavioral Health Claims Job Aid
- Federally Qualified Health Centers Contracting with Medicare Advantage Plans
- Fee-For-Time Compensation Arrangement and Reciprocal Billing Job Aid
- Answers to Common Fee-for-Time Compensation Arrangements Questions
- FQHC and Group Therapy Services Job Aid
- Hospital Acquired Conditions and Present on Admission Resource for Acute Care Hospital Facilities
- Long-Term Care Hospitals: How to Request Adjustments of Claims Paid at the Site Neutral Rate
- Inhalation Treatment CPT 94640 – Billing Errors
- Immunization Roster Billing
- JK: Medicare Paid Hospital Providers Twice for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient IPPS Hospital Stays
- Nonphysician Practitioners Billing for Surgical Procedures
- Professional Services During a Patient Hospice Election
- Professional Services During a Patient Hospice Election
- Proper Billing for Finger and Toe Procedures
- Proper Submission of Fee-For-Time Compensation Arrangements and Reciprocal Billing Arrangements
- Proper Use of Taxonomy Codes
- A/B Rebilling Facts
- Common Reciprocal Billing Questions and Answers
- Reminder for Avoiding Claim Denials for Positron Emission Tomography Scans
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
- Repetitive Outpatient Services for Providers Submitting Institutional Outpatient Claims
- Reporting Multiple Qualifying Visits on the Same Date of Service for FQHC Reimbursement
- Unlisted and Not Otherwise Classified Procedure Codes
- What All Facilities Need to Know About the Long-Term Care Hospital Three-Day or Less Interrupted Stay Policy
- Fiscal Year/Calendar Year Claim Split
- Hospitals Must Correctly Assign Severe Malnutrition Diagnosis Codes to Inpatient Claims
Reminder for Avoiding Claim Denials for Positron Emission Tomography Scans
Background
It has been noted that a high volume of PET scan claims falling between the CPT code range 78811–78816 are being denied upon original claim submission due to a nonspecific diagnosis code for cancer being used.
It’s imperative that providers are coding the diagnosis to the highest level of specificity known. By coding the beneficiaries’ specific cancer diagnosis, claims will likely not be denied for this reason and subsequently not have to go through the appeals process.
CMS continues to nationally cover one Fluorodeoxyglucose (18F) (FDG) PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary’s treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial anti-tumor treatment strategy:
- to determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure; or
- to determine the optimal anatomic location for an invasive procedure; or
- to determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.
Effective for claims with dates of service on and after 6/11/2013, the chart below summarizes national FDG PET coverage for oncologic conditions:
| FDG PET for Cancers Tumor Type |
Initial Treatment Strategy (formerly “diagnosis” and “staging") |
Subsequent Treatment Strategy (formerly “restaging” and “monitoring response to treatment” |
|---|---|---|
| Colorectal | Cover | Cover |
| Esophagus | Cover | Cover |
| Head and Neck (not thyroid, CNS) | Cover | Cover |
| Lymphoma | Cover | Cover |
| Non-small cell lung | Cover | Cover |
| Ovary | Cover | Cover |
| Brain | Cover | Cover |
| Cervix | Cover with exceptions * | Cover |
| Small cell lung | Cover | Cover |
| Soft tissue sarcoma | Cover | Cover |
| Pancreas | Cover | Cover |
| Testes | Cover | Cover |
| Prostate | Noncovered | Cover |
| Thyroid | Cover | Cover |
| Breast (male and female) | Cover with exceptions * | Cover |
| Melanoma | Cover with exceptions * | Cover |
| All other solid tumors | Cover | Cover |
| Myeloma | Cover | Cover |
| All other cancers not listed | Cover | Cover |
*Cervix: Nationally noncovered for the initial 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 noncovered for initial diagnosis and/or 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: Nationally noncovered for initial staging of regional lymph nodes. All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.
Related Content
Revised 11/3/2023