2009 Reimbursement Update for Imaging Centers paid under PFS
CMS recently issued its 2009 Final Medicare Physician Fee Schedule (MPFS) Rule.
For the Physician Fee Schedule, which includes payments to all IDTF's, there were very few changes to PET reimbursement in 2009.
CMS continues with Packaging of Diagnostic Radiopharmaceuticals
For calendar year 2009, radiopharmaceuticals should be billed separately and reimbursed based on invoice, fee schedule or AWP. FDG does not have a published AWP, so the most payers will use the invoice or fee schedule methodology. Radiopharmaceuticals should be billed with the following codes:
A9552 FDG, per dose
A9555 Rb82, per dose
A9526 Ammonia, per dose
A9580 Sodium Fluoride, per dose (not covered by CMS)
CMS continues with DRA Requirements
In accordance with the Deficit Reduction Act, the OPPS cap remains in effect for 2009. This means that the rates paid in the PFS and IDTF environment will be capped at the amount paid in the HOPPS environment.
| 2008 - 2009 OPPS Cap and Professional Fees Comparison |
| CPT |
TC Rate 2008 |
TC Rate 2009 |
Prof Rate 2008 |
Prof Rate 2009 |
| 78811 | $1057.30 | $1036.91 | $76.17 | $80.43 |
| 78812 | $1057.30 | $1036.91 | $94.07 | $99.90 |
| 78813 | $1057.30 | $1036.91 | $97.50 | $103.51 |
| 78814 | $1057.30 | $1036.91 | $106.64 | $113.25 |
| 78815 | $1057.30 | $1036.91 | $118.07 | $125.15 |
| 78816 | $1057.30 | $1036.91 | $120.74 | $128.40 |
| 78459 | $1400.84 | $1157.02 | $76.65 | $79.35 |
| 78491 | $1400.84 | $1157.02 | $75.79 | $80.43 |
| 78492 | $1400.84 | $1157.02 | $96.74 | $101.35 |
Codes 78890 and 78891 deleted in 2009
CPT codes 78890 and 78891 for computer processing were deleted effective January 1, 2009. The rationale being that the current PET systems perform the computer processing automatically and thus CMS will no longer reimburse for these codes.
Disclaimer
This information provided by PETNET Solutions is based on published guidelines and on our experience, and is provided for general information only, as a service and at no charge to our customers. It is based on information found in published CMS National Coverage documents, but is not all-inclusive. We believe that the information set forth herein is generally accurate; however, we cannot provide assurance that it is complete, accurate or current. Always check with your local insurance carriers, as coverage may vary by region. The referring physician is responsible for pre-authorization and providing proof of medical necessity for any PET scan. PETNET Solutions and its representatives hereby expressly disclaim any and all liability for claims, including bodily injury or death, arising from any reliance on the information set forth herein.