AMI Says Prepare for Changes in PET Coverage Under NOPR

February 20, 2009 - The Academy of Molecular Imaging recommends that PET imaging facilities closely monitor NOPR communications and be prepared for coverage changes on the date the final coverage decision is issued.

On January 6, 2009, CMS proposed significant changes to current coverage regarding Medicare's coverage of PET imaging under NOPR (see http://). Under the proposal, Medicare will provide coverage on a routine basis for many of the indications now reimbursed under NOPR. However, other indications would be covered only under a successor Coverage with Evidence Development (CED) program which likely will be somewhat different than the current NOPR program.

Medicare will publish its final coverage statement on or before April 6, 2009. The new policy becomes effective on the day it is published. The NOPR believes it should be possible to have a successor CED program in place when the NCD is published. However, until the day the new NCD is published, we will not know the details of the final coverage policy, whether any new codes or modifiers must be used for claims, nor whether a successor NOPR program has been cleared by CMS.

Although the new coverage policy will be effective on the day it is published, Medicare Contractors are allowed at least 30 days to implement required changes in their claims processing software, and in
their local coverage policies.

Each site should closely monitor NOPR communications, and be prepared for coverage changes on the date the final coverage decision is issued. In the past, when major coverage or fee schedule changes occurred, some providers have held claims until their contractors have implemented the new edits. As soon as additional information becomes available, we will make it available to participating PET facilities via these e-mail announcements and the NOPR website.

For more information: www.ami-imaging.org and www3.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=218