Weathering the CMS processing freeze on FDG PET: Tips and pointers

Medicare’s temporary freeze on payments for certain PET scans of solid tumors, which began Oct. 6 and won’t end until Nov. 11, came as no surprise. The agency announced last spring that it needed time to test and edit this part of its claims-processing system.

In late September, the agency sent word via the Medicare Learning Network Provider eNews that, once the freeze is over and the changes are in place, Medicare will foot the bill for up to three Fluorodeoxyglucose (FDG) PET scans per tumor. Additional scans may be covered, payable through private Medicare administrative contractors (MACs), if the contractor agrees with the provider that additional scans beyond three are medically necessary.

CMS stated that no action is required by providers while its accuracy-calculation work is underway.

Mark Isenberg, a partner with the Indiana-based medical billing firm Zotec Partners, said radiology provider groups and facilities that submit claims likely to be affected by the freeze would do well to:

  • submit claims as usual to Medicare and specifically to other payors who are neither implementing the edits nor freezing claims;
  • track the claims on hold with CMS and ensure processing occurs promptly after November 11; and
  • concurrently review your local MAC’s website for any further updates to the freeze announcement.

“Provider groups would be well advised to also ensure their documentation practices are refined as these edits are implemented,” Isenberg told imagingBiz. “A comprehensive history—and more specific description of the medical necessity for the [post-third] subsequent study—will be beneficial in the accuracy of coding and proper reimbursement of these services.”

Isenberg added that providers may also want to consider of the use of an advance beneficiary notice as necessary.

For additional information from Medicare on its FDG PET processing freeze, click here