Know more about Amyloid Imaging.
Evidence for Amyloid Scanning (IDEAS) Study is a Medicare-approved coverage with evidence development (CED) procedure. This nuclear medicine procedure uses positron emission tomography (PET) imaging to examine how amyloid plaques (a core feature of Alzheimer?s disease) in the brain help to guide doctors in patient treatment, and whether these changes in treatment lead to better medical outcomes. The IDEAS Study (activated Feb. 8, 2016) provides access to amyloid imaging for more than 18,000 patients for whom the cause of cognitive decline/dementia is ambiguous, and who may benefit from an early and accurate diagnosis.
A PET imaging facility may not perform an IDEAS Study PET scan unless they are enrolled in the IDEAS program, and until the referring physician has submitted a pre-PET clinical assessment form for the patient to the IDEAS Study database. After the PET scan is completed and the appropriate data uploaded to the IDEAS Study database, a system-generated notification is sent from the email address IDEAS-Study@acr.org to the PET imaging facility, indicating the case data are complete. Only after the email notification is received may the PET facility and the reading physicians begin to bill Medicare for the study and the radiopharmaceutical.
Reading physicians should coordinate with the PET imaging facility to obtain a copy of the system-generated notification prior to billing for PET studies reading. Both the PET imaging centers and the reading physician should maintain the email notification for each patient study as documentation, in case the Centers for Medicare & Medicaid Services (CMS) opts to audit the PET imaging facility.
The PET facility (and the interpreting physician, if technical and professional component billing are performed separately) may submit the claim for the service to the local Medicare administrative contractor (MAC) or Medicare Advantage (MA) plan, as appropriate.
It should be noted that Amyloid imaging services are currently not covered by any third-party payers.
Following are some tips to avoid common omissions/errors on IDEAS claim submissions:
- Providers should append modifier Q0 to the HCPCS Level II radiopharmaceutical codes. This is in addition to appending modifier Q0 to the CPT(R) procedure code for the PET study. MACs say this is the main issue that causes IDEAS claim denials.
- Providers should include the appropriate clinical trial number following CMS Transmittal 2955 (CR 8401, May 13, 2014). Examples are also provided by IDEAS in the Sample Medicare Claims on the IDEAS website.
- Independent diagnostic testing facilities (IDTF) should verify that the CPT(R) and HCPCS Level II codes to be used for IDEAS scans are on their CMS-855B form and accepted by the MAC for use prior to billing for IDEAS studies. This issue is the No. 1 issue for IDTF claim denials in IDEAS.
- If a payer instructs you to append modifier PI Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing or modifier PS Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary?s treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy to either the CPT(R) or HCPCS Level II codes on the claim, be aware that this is not a CMS billing requirement of IDEAS claims. Please notify Denise Merlino or the IDEAS team immediately with sample claims using the Claim Denial Form process noted.
- If an MA plan denies prior authorization for an IDEAS patient, it?s recommended you appeal all denials. Specifically, follow up with additional documentation to support your request, ?This patient is enrolled in the CMS approved CED program IDEAS and provide the MA plan,? with the three references below:
A copy of the link to the CMS communication to MA plan.
A copy of the link to the IDEAS FAQ, specifically guiding them to the question:
Will managed Medicare plans (Medicare Advantage) reimburse for scans done as part of the IDEAS Study?
Yes, Medicare Advantage (MA) beneficiaries are eligible to be included in the IDEAS Study. The MA plans will make payments for MA enrollees. IDEAS Study claims should be billed to the MA plan. This policy is located in Publication 100-16, Chapter 4: Managed Care Manual 10.7.3 ? Benefits and Beneficiary Protections ? Payment for Clinical Studies Approved Under Coverage with Evidence.
There are many important elements to a CMS CED-approved study. If any element is not performed or not on the claim, the claim will likely deny for payment, or be considered by Medicare as not covered. Merlino Healthcare Consulting Corp. has been working with MACs regarding some claims processing issues to resolve them as quickly as possible. At the time this article was written, Noridian was updating the list of ICD-10 codes payable with only modifier Q0 for claims processing.