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TRANSCRIPT
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NOPRNOPRNational Oncologic PET RegistryNational Oncologic PET Registry
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Medicare Reimbursement for Oncologic PET (2005)
• Diagnosis, staging, and restaging of:Non-small cell lung cancer Lymphoma
Esophageal cancer Malignant melanoma
Colorectal cancer Head and neck cancer
• Staging, restaging, and Rx monitoring of breast cancer• Detection of TG+/RAI– thyroid cancer• Staging of cervical cancer (– CT/MRI outside pelvis)• All other cancers/indicationsAll other cancers/indications
– National registryNational registry
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NOPR• Is a CMS-approved
– “Coverage with Evidence Development” Program• Developed for the November 2004 expansion by CMS
– All other cancers and indications except:• Breast cancer diagnosis and axillary staging• Melanoma regional nodal staging
• All PET facilities can participate (for a fee)• Requires timely Pre-PET and Post-PET information• All data will be submitted to CMS • Cases with patient and physician consent will be used by
the NOPR to assess change in intended management
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NOPRNOPRNational Oncologic PET RegistryNational Oncologic PET Registry
NOPRNOPRNational Oncologic PET RegistryNational Oncologic PET Registry
Sponsored by
Managed byAdvisor
Endorsed by
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Objectives & Goals
• Objectives – Assess the effect of PET on referring physicians’ plans of
intended patient management • across a wide spectrum of cancer indications for PET that
are currently not covered by the Medicare program, and• in relation to cancer-type, indication, performance status,
physician’s role in management, and type of PET.
• Goal– Acquire data that can be used to evaluate PET in a manner
that does not interfere with patient clinical care and minimizes the burden to the patient, PET center, and referring physician.
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Data Analysis and Expected Results
• Data analyzed by cancer type and indication (reason for PET).
• For the most frequent cancer indications, interim analysis will be performed at N=200 to refine sample size estimates.
• If the frequency of change in intended management for a particular cancer indication is sufficient to suggest benefit, data (along with summary of published literature) will be provided to CMS with request for coverage.
• Eventual goal is to achieve broad coverage through analysis of data across all cancers and indications.
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Institutional Review Board (IRB) Approval & Subject Informed Consent
• Is this research? Yes, but only for the NOPR. Individual PET facilities and referring physicians are not engaged in research.
• Is IRB approval needed? Yes. ACR IRB has approved the NOPR. Individual PET facilities and referring physicians do not need to obtain IRB approval to participate.– All data will be sent to CMS. CMS is not engaged in research.
– Patients and referring physicians will be given an IRB-approved information sheet and asked for oral consent to have their data included in NOPR research.
– Only cases where both patient and physician give consent will be included in the NOPR research dataset.
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Patient Informational Sheet
Available at CancerPETregistry.org
Referring Physician Information Sheet
•Available in English and Spanish
•Also Sent with Post-PET Form to Referring Physician
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HIPAA Requirements
• HIPAA requirements met through execution of a Business Associates Agreement with the American College of Radiology as an agent for the Academy of Molecular Imaging and CMS.
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Participation Requirements - PET Facilities
• Any PET facility that is approved to bill CMS for either technical or global charges can participate in the NOPR.
• Facilities are not required to have or obtain ACR or ICANL accreditation.
Participation Requirements - Patients
• Medicare beneficiaries, including those with Medicare HMO coverage, who are referred for FDG-PET for essentially all oncologic indications that are not currently reimbursable under Medicare.
• The Indications table lists the cancers and indications that are and are not eligible for the Registry.
• Oral consent is necessary for inclusion in the NOPR research dataset; however, no consent is necessary to submit data to NOPR that will be sent to CMS.
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PET Facility Responsibilities• Collect and enter all required data through the NOPR Web site.
– Patient must be registered within 14 days of the PET scan date– Give patient the Patient Information Sheet– Pre-PET Form must be entered by midnight of the PET scan date– PET Completion Form must be entered within 14 days of case registration– The PET Report & Post-PET forms must be entered within 30 days of scan
• PET facility is eligible to bill CMS when all required data are received at NOPR Operations Office.
Referring Physician Responsibilities• Complete Pre-PET Form (5 questions) and return it to PET Facility prior to PET scan.
• Complete Post-PET Form (4 - 7 questions) and return it to PET Facility within 30 days of PET scan.
• Pre- and Post-PET forms can be returned to the PET facility via FAX, mail, or hand delivery.
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Ineligible Indications
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Cancers & Indications Eligible for Entry in the NOPR
continued on next slide
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Cancers & Indications Eligible for Entry in the NOPR(continued)
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Does NOPR Apply to Oncologic PET with Radiopharmaceuticals other than FDG?
• No
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Facility and Patient Registration
• Register via the NOPR Web site www.cancerPETregistry.org– Complete Facility Registration Form
• PET facility information including Medicare Provider Number
• PET facility administrator (the individual responsible for managing registry activities at the facility)
• Participating interpreting physician(s)
• Equipment details
• Submit Executed Business Associates Agreement (BAA)• $50 Facility Application Fee• $50 Processing Fee for Each Patient
– Advance payment held in escrow account
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NOPR Web Site
• Information for – PET Facilities– Referring Physicians– Patients
• Blank Forms• Register PET Facilities• Register Patients• PET Facility Tools
– Case Status Reports– Account Balance– Fund Account by Credit
Card
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Pre-PET Form – 5 Questions
• Reason for the PET Scan• Cancer Site/Type• Summary of Disease Stage
– NED, Localized, Regional, Metastatic, Unknown
• Performance Status– Asymptomatic, Symptomatic, Bedridden
• Intended Patient Management Plan
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Pre-PET Form: Specific Reason For PET
Diagnosis: To determine if a suspicious lesion is cancer Diagnosis
Unknown primary tumor: To detect a primary tumor site in a patient with a confirmed or strongly suspected metastatic lesion
Paraneoplastic: To detect a primary tumor site in a patient with a presumed paraneoplastic syndrome
Initial staging of histologically confirmed, newly diagnosed cancer Monitoring treatment response: during chemotherapy, radiotherapy, or
combined modality therapy Restaging after completion of therapy Suspected recurrence of a previously treated cancer
1. Check the single best match for the reason for the PET.
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Pre-PET Form: Intended Patient Management Plan
Observation (with close follow-up) Additional imaging (CT, MRI) or other non-invasive diagnostic tests Tissue biopsy (surgical, percutaneous, or endoscopic). Treatment (if treatment is selected, then also complete the following)
Treatment Goal: (check one) Curative Palliative
Type(s): (check all that apply)
– Surgical Chemotherapy (including biologic modifiers)
– Radiation Other Supportive care
5. If PET were not available, your current management strategy would be (select one)?
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Pre-PET Web Form
2.
42 Primary and Metastatic Sites Listed
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Pre-PET Web Form continued
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Post-PET Form – 4 to 7 Questions
• Questions Customized by Specific Reason for PET (Indication)
• 4 - 7 Questions per Indication• Most Require a Yes or No Answer• 2 Questions are Repeated from the Pre-PET Form
– Intended Patient Management Plan
– Planned Cancer Care Provider
• Referring Physician Consent
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Referring MD Requests PETReferring MD Requests PET
Pre-PET Questionnaire
Pre-PET Questionnaire
PETDonePET
Done
PET Reviewed
& Reported
PET Reviewed
& Reported
Post-PETQuestionnaire
Sent Includes Question for Referring Physician
Consent
Post-PETQuestionnaire
Sent Includes Question for Referring Physician
Consent
Questionnaire Completed
$$
Questionnaire Completed
$$
Clinical Actions Ongoing
Clinical Actions Ongoing
NOPR Workflow
Ask Patient For ConsentAsk Patient For Consent
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Timeline• Timeline available on
NOPR Website.
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Billing
• Hold claims until all data is entered in the Registry• Notify reading physicians when all data is entered into
NOPR and the PET facility has the NOPR e-mail verification
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Timeline
Providers Bill MedicareUsing Appropriate
Claim Form & Codes
Hospitals Use Hospitals Use UB/1450 Claim Form
Technical Only
Non-Hospitals Use Non-Hospitals Use 1500 Claim Form
Professional/Technical/Global
No Waiting Period
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FDG-PET Procedure and Supply Codes
2006HCPCS Code
Description
78811 Tumor imaging, positron emission tomography (PET); limited area (eg, chest, head/neck)
78812 Tumor imaging, positron emission tomography (PET);
skull base to mid-thigh
78813 Tumor imaging, positron emission tomography (PET); whole body
78608 Brain imaging, positron emission tomography (PET); metabolic evaluation
A9552 Fluorodeoxyglucose F-18 FDG, diagnostic,
per study dose, up to 45 millicuries
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FDG-PET/CT Procedure and Supply Codes
2006HCPCS Code
Description
78814 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization;
limited area (eg, chest, head/neck)
78815 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh
78816 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body
A9552 Fluorodeoxyglucose F-18 FDG, diagnostic,
per study dose, up to 45 millicuries
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For Carriers on 1500 Claim Form Use Modifier
2006
HCPCS Modifier
Description
QR Item or service provided as routine care in a Medicare specified study or Medicare qualifying clinical trial
Modifier Use by Providers to Identify NOPR ClaimsUse only with procedure, not necessary with the radiopharmaceutical billed on the same DOS as the procedure.
CMS Transmittal 956, 5/19/06
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Hospitals ONLY on 1450 Claim Form (UB)
2006Hospital
Revenue/ICD 9 CM Codes
Description
0343 Diagnostic Radiopharmaceutical
0404 PET Procedures
V70.7 Examination of participants in clinical trial
V70.7 Use in the Second Diagnosis Position FL 68From Current CMS policy CR 3741
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A 72-year-old woman with diffuse large cell non-Hodgkin's lymphoma is undergoing chemotherapy with R-CHOP. PET/CT (skull-base to proximal thigh) is requested after the second cycle of treatment for monitoring of therapy.
2006Hospital Revenue
Code
2006HCPCS/
ICD 9 CM Codes
Description
0404 78815 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh
0343 A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
N/A 202.80 Other Lymphomas (malignant): Not otherwise specified (NOS)
Case 1Case 1
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Use of PET for Treatment Monitoring under NOPR
• One potential problem may be “collision” of NOPR intent with individual carrier frequency limits for PET studies
• Could lead to rejection of claim (or refusal of Medicare Advantage plan to pre-authorize study)
• Please notify NOPR staff if this occurs!
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A 67-year-old man has a history of glioblastoma multiforme of left parietal lobe treated with surgery, radiation therapy, and temazolamide. Follow-up MRI demonstrates a new 8 mm focus of contrast enhancement adjacent to the original tumor bed. Brain PET is requested for restaging, to distinguish recurrent tumor for radiation necrosis.
2006Hospital Revenue
Code
2006HCPCS/
ICD 9 CM Codes
Description
0404 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation
0343 A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
N/A 191.3 Malignant neoplasm of brain, parietal lobe
Case 2Case 2
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A 68-year-old woman has newly diagnosed dermatomyositis and progressive weight loss. CT of the chest, abdomen, and pelvis demonstrated no evidence of malignancy. Whole-body PET/CT is requested to detect an occult malignancy as the cause of her paraneoplastic syndrome.
2006Hospital Revenue
Code
2006HCPCS/
ICD 9 CM Codes
Description
0404 78816 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body
0343 A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
N/A 710.3 Dermatomyositis
N/A 783.21 Abnormal Loss of Weight
Case 3Case 3
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Advance Beneficiary Notice (ABN)
• A PET facility can ask registry patients to sign an ABN. This decision is left up to each PET facility. However, an ABN should not be necessary. If patient eligibility is carefully checked before the patient is entered into the registry and before the PET scan is performed and if the facility works closely with its referring physicians to ensure that the required paperwork is submitted in a timely fashion, there will be no need to obtain ABNs.
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Medigap Insurance for Co-Payments
• Medigap insurance should cover the co-payment for a registry PET scan, as for any other Medicare covered service.
Managed Medicare Plans – Medicare Advantage
• Managed Medicare plans such as Medicare Advantage should pay any claims that would be covered by Medicare.– Follow Pre-Authorization as required by the plan
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Will non-Medicare insurers reimburse for patients entered in the Registry?
• No, there are no non-Medicare insurers who have elected to reimburse for patients entered in the registry. Patients with insurance coverage other than Medicare, including Medicaid, are not eligible to participate in the NOPR.
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Does NOPR Apply to Inpatients?
• Yes.
• The technical charge for a PET study on a Medicare inpatient is not billed directly, but is considered to be covered by the Diagnostic Related Grouping (DRG) payment to the hospital for that patient.
• Inclusion of the patient in the NOPR is necessary, however, for professional component reimbursement for the PET study.
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I have registered my facility with NOPR and have not sent any money. What do I need to do NOW to prepare for a smooth transition?
• Download IRB Regulatory Materials & Operations Manual; implement the required procedures.
• Put systems in place to identify (up front) NOPR patients and put triggers into billing systems to hold claims (back end). If external MD reading, ensure the reader does the same.
• Meet/communicate with referring physicians regarding required forms/timelines and set up efficient processes prior to accepting patients.
• Decide how your facility will handle ABNs for NOPR patients.• Print patient and physician consent information sheets for
appropriate distribution.• Download and review the database instruction manual.
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NOPR Working Group
• Chair, Bruce Hillner, MD, Virginia Commonwealth University
• Co-chair, Barry A. Siegel, MD, Washington University
• R. Edward Coleman, MD, Duke University
• Anthony Shields, MD, Wayne State University
• Statistician: Dawei Liu, PhD, Brown University
• Epidemiologist: Ilana Gareen, PhD, Brown University
NOPR Operations OfficeAmerican College of Radiology1818 Market Street, Suite 1600Philadelphia, PA 19103215-717-0859800-227-5463 x 4859
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Endorsing Organizations’ Educational Contacts
• Academy of Molecular Imaging– Sue Halliday, [email protected]
• American College of Radiology– Joy Brown, [email protected]
• American College of Radiology Imaging Network– Nancy Fredericks, [email protected]
– Barbara LeStage, Patient Advocate, [email protected]
• American Society of Clinical Oncology– Nancy Daly, [email protected]
• Society of Nuclear Medicine– Denise Merlino, [email protected]
