The National Government Services has agreed to evaluate and consider altering its reimbursement codes for PET/CT procedures for Medicare beneficiaries

National Government Services to evaluate Medicare PET/CT reimbursement

May 26, 2021
by John R. Fischer, Senior Reporter
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.

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.

SNMMI and other groups argued that making cuts like this on such short notice was unsustainable and may lead to practice disruptions that could hinder access to PET services. “One issue relates to CMS using the 90 percent utilization rate rather than the Relative Value Scale Update Committee (RUC)-recommended 50 percent utilization rate for the PET equipment. SNMMI is asking its members to provide updated equipment invoices so that CMS can get the costs of all the equipment correct,” Caitlin Kubler, SNMMI associate director of health policy and regulatory affairs, told HCB News at the time.

The proposal was later delayed before the schedule went into effect in January 2020.

In a statement, ACR said that current payment rates were inaccurate and needed to be reformed with new and revised codes. “The letter references previous discussions with NGS and contends it should not use ambulatory surgical center rates to pay for physician office service, stating that those rates do not appropriately reflect the cost of performing a service in the office setting.”