Not just three scans: Understanding FDG PET coverage

The Centers for Medicare & Medicaid Services provided a reiteration of the agency’s national coverage decision regarding oncologic FDG PET this summer and clarified specifically the –KX modifier that needs to be used when clinicians code for the fourth scan and beyond.

Today IBA Molecular reported this note from CMS:

“For clarification purposes, as an example, each different cancer diagnosis is allowed one (1) initial treatment strategy (-PI modifier) FDG PET Scan and three (3) subsequent treatment strategy (-PS modifier) FDG PET Scans without the -KX modifier. The fourth FDG PET Scan and beyond for subsequent treatment strategy for the same cancer diagnosis will always require the -KX modifier. If a different cancer diagnosis is reported, whether reported with a -PI modifier or a -PS modifier, that cancer diagnosis will begin a new count for subsequent treatment strategy for that beneficiary. A beneficiary's file may or may not contain a claim for initial treatment strategy with a -PI modifier. The existence or non-existence of an initial treatment strategy claim has no bearing on the frequency count of the subsequent treatment strategy (-PS) claims.”

A full reprisal of recent changes to the decision can be found in the CMS Transmittals R2932CP, dated April 18, and R168NCD, dated May 28.