Medicare Transmittal 956 CR 5124 May 19, 2006

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Medicare Transmittal 956 CR 5124 May 19, 2006

• NOPR Billing Instruction Clarification
• Physician Offices/IDTF use QR Modifier
• Hospitals use QR and V70.7
• MLM CMS Educational Article MM5124
• Published May 31, 2006

CMS Effective January 28, 2005 NOPR Opened May
8, 2006 NOPR Patients DOS Effective May 8, 2006
Implemented by Medicare Contractors June 19th
2006 Noridian Empire QR modifier system errors
corrected!
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Timeline
No Waiting Period
Hold claims until all data entered into the
Registry
Providers Bill Medicare Using Appropriate Claim
Form Codes
Hospitals Use UB/1450 Claim Form Technical Only
Non-Hospitals Use 1500 Claim Form Professional/Te
chnical/Global
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FDG-PET Procedure and Supply Codes
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FDG-PET/CT Procedure and Supply Codes
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For Carriers on 1500 Claim Form Use Modifier
Modifier Use by Providers to Identify NOPR
Claims Use only with procedure, not necessary
with the radiopharmaceutical billed on the same
DOS as the procedure.
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Hospitals ONLY on 1450 Claim Form (UB)
V70.7 Use in the Second Diagnosis Position FL
68 From Current CMS policy CR 3741
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A 72-year-old woman with diffuse large cell
non-Hodgkin's lymphoma is undergoing chemotherapy
with R-CHOP. PET/CT (skull-base to mid thigh) is
requested after the second cycle of treatment for
monitoring of therapy.
Case 1
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Use of PET for Treatment Monitoring under NOPR

• One potential problem may be collision of NOPR
  intent with individual carrier frequency limits
  for PET studies
• Could lead to rejection of claim (or refusal of
  Medicare Advantage plan to pre-authorize study)
• Please notify NOPR staff is this occurs!

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A 67-year-old man has a history of glioblastoma
multiforme of left parietal lobe treated with
surgery, radiation therapy, and temazolamide.
Follow-up MRI demonstrates a new 8 mm focus of
contrast enhancement adjacent to the original
tumor bed. Brain PET is requested for restaging,
to distinguish recurrent tumor for radiation
necrosis.
Case 2
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A 68-year-old woman has newly diagnosed
dermatomyositis and progressive weight loss. CT
of the chest, abdomen, and pelvis demonstrated no
evidence of malignancy. Whole-body PET/CT is
requested to detect an occult malignancy as the
cause of her paraneoplastic syndrome.
Case 3
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Advance Beneficiary Notice (ABN)

• A PET facility can ask registry patients to sign
  an ABN. This decision is left up to each PET
  facility. However, an ABN should not be
  necessary. If patient eligibility is carefully
  checked before the patient is entered into the
  registry and before the PET scan is performed,
  and if the facility works closely with its
  referring physicians to obtain the required
  paperwork in a timely fashion, there should be no
  need for ABNs.

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Medigap Insurance for Co-Payments

• Medigap insurance should cover the co-payment for
  a registry PET scan, as for any other Medicare
  covered service.

Managed Medicare Plans Medicare Advantage

• Managed Medicare plans such as Medicare Advantage
  should pay any claims that would be covered by
  Medicare.
• Follow Pre-Authorization as required by the plan

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Will non-Medicare insurers reimburse for patients
entered in the Registry?

• No, there are no non-Medicare insurers who have
  elected to reimburse for patients entered in the
  registry. Patients with insurance coverage other
  than Medicare, including Medicaid, are not
  eligible to participate in the NOPR.

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Does NOPR Apply to Inpatients?

• Yes.
• The technical charge for a PET study on a
  Medicare inpatient is not billed directly, but is
  considered to be covered by the Diagnostic
  Related Grouping (DRG) payment to the hospital
  for that patient.
• Inclusion of the patient in the NOPR is
  necessary, however, for professional component
  reimbursement for the PET study.