National Government Services to evaluate Medicare PET/CT reimbursement

por John R. Fischer, Senior Reporter | May 26, 2021
Business Affairs Cardiology CT Molecular Imaging X-Ray
The National Government Services has agreed to evaluate and consider altering its reimbursement codes for PET/CT procedures for Medicare beneficiaries
In response to concerns around Medicare coverage for PET/CT, National Government Services has agreed to evaluate reimbursement for such exams.

“We agree that PET CT should be reimbursed higher than PET alone. We will be making some changes in reimbursement,” said Dr. Stephen Boren, medical director of NGS, in a statement.

The decision follows a letter sent May 11 by the Society of Nuclear Medicine & Molecular Imaging, the American College of Radiology and other organizations concerned about payment and access to myocardial PET imaging.
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Specifically, they requested that codes for Medicare payment be set up in a way that accounts for cost differences associated with different types of exams, including those with PET and without CT. “We strongly recommend that [National Government Services] determine appropriate rates for the myocardial PET procedures by recognizing that within the family of codes, there is a hierarchy in the complexity, time to perform, and resource costs of the procedures,” wrote the imaging groups.

They suggest using a single perfusion study as a starting point, as it is the simplest and least pricey procedure. NGS could use it as a reference to set payment rates for more complex exams, with a single metabolic evaluation costing 10% more than single perfusion, say the groups, while performing a CT scan concurrent with a PET procedure would cost 28% more for additional equipment.

They also called for providers to be able to perform such procedures in office-based environments, as it allows patients to receive services “in a more timely manner” and “in a more accessible setting” compared to hospitals. “Such access is particularly important during the COVID-19 public health emergency, when hospitals are often overwhelmed treating COVID patients and when non-COVID patients may be reluctant to obtain services at hospitals for fear of exposure.”

Prior to the COVID-19 pandemic, PET scans were on an upward trajectory, growing at about 6% annually.

The Centers for Medicare & Medicaid Services caused a stir back in 2019 when it proposed reductions as deep as 80% to myocardial PET service payments as part of its Medicare Physician Fee Schedule for 2020. This, it said, was in line with procedure terminology code changes made at the time for reporting services, a review of the direct practice expense inputs for the technical component pay, and CMS’ decision to assume a 90% utilization rate for PET cameras.

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