June 6, 2023
On March 22, SNMMI and the American College of Radiology (ACR) sent a joint letter to the Center for Medicare and Medicaid Services (CMS) in regard to proposed and existing edits to SPECT and SPECT/CT nuclear medicine coding.
We believe there was an error in the revised SPECT and SPECT/CT nuclear medicine codes transition and implementation in 2020. SNMMI has sent several letters requesting corrections to those codes; however, there are still several additional edits that have yet to be reversed, such as the code pair CPT 79101—Radiopharmaceutical Therapy by Intravenous Administration and the SPECT and SPECT/CT codes 78830–78832. Another example of procedures typically done on the same day after treatment is LU-177 DOTATATE and Lu-177 PSMA. Until these retroactive changes are made, patients are not only inconvenienced but also at risk as the new guidance requires the performance of separate procedures on separate dates of service. In our recent joint letter, we also requested that several PTP edits to be deleted, including 79101-78800, 78801, 78802, 78803, 78804, 78805, 78806, 78807, 78808, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832.
We received a response from CMS acknowledging receipt of our letter and clarification of some of the PTP edits. The response included the following information: between column one CPT code 79101, Radiopharmaceutical Therapy by Intravenous Administration, and the column two SPECT and SPECT/CT codes in the range 78830-78832 noting that the edits with CCMI of one allows the use of an NCCI PTP associated modifier 59 to bypass the edit if the requirements for use of the modifier are met.
Based on the information submitted, CMS is changing the CCMI of zero to one in order to allow a bypass for column 1 code CPT 79101 paired with column 2 codes 78830, 78831, and 78832. However, CMS decided to keep the CCMI of one for column one code CPT 79101 paired with column 2 codes 78800, 78801, 78802, 78803, 78804, 78808, 78811, 78812, 78813, 78814, 78815, and 78816. These modified edits are in the third quarter NCCI updates to be implemented July 1, 2023.
We are continuing to talk with CMS about making these changes retroactive; the recent update did not include updating to retroactive for the last year. Providers should keep a listing of these claims and talk to their local Medicare contractor or payer to request manual payments. We also discussed in the letter proposed changes to MUE edits for the radiotracers, which include two diagnostic codes A9602 and A9800 as well as one therapeutic code A9607. CMS was receptive to all of our suggestions.
For the proposed changes indicated above, the edits were implemented to be effective for claims with a date of service on July 1, 2023.
For more information or to identify any additional problematic edits contact HPRA@advocacy.org.