Recovery Audit Contractors Set Their Sights on PET Scans for Initial Treatment in Oncological Conditions

August 10, 2021

CPT® Codes 78608, 78811, 78812, 78813, 78814, 78815, 78816, A9552

Recovery Audit Contractors (RACs) are selected by CMS to review claims on a post-payment basis with the objective of identifying and correcting improper payments made on claims for healthcare services provided to Medicare beneficiaries.  

“Improper” can refer to overpayments or underpayments.  Overpayments are determined to have occurred when auditors deem the supplied documentation for a paid service does not meet Medicare’s coding and/or medical necessity policies.  Likewise, underpayments are identified when medical records indicate a more extensive service was provided than what was billed and paid for.

RACs are paid on a contingency fee basis, meaning they are reimbursed based on a percentage of the improper payments they find.  However, they are required to return the fee if their overpayment/underpayment determination is overturned through any level of provider appeal.

CMS recently added PET scans to its RAC work plan as described below.  The scope of the audit includes claims filed for professional and hospital outpatient services in all Medicare A/B MAC jurisdictions.

0206-Positron Emission Tomography (PET) for Initial Treatment Strategy in Oncologic Conditions: Medical Necessity and Documentation Requirements

Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) is covered only in clinical situations in which PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal location to perform an invasive procedure. PET would also be considered reasonable and necessary when clinical management of the patient would differ depending on the staging of the cancer identified, and in clinical situations in which the stage of the cancer remains in doubt after completing a standard diagnostic workup or it is expected that conventional imaging study information is insufficient for clinical management of the patient. Medical records will be reviewed to determine if the utilization of FDG PET studies for initial anti-tumor treatment strategy are medically necessary according to Medicare coverage indications.

You can access CMS’ list of applicable policy references for this audit here.

There are currently three RACs contracted to perform audits across five regions: Performant Recovery, Inc., Cotiviti, LLC and HMS Federal Solutions.  Click here for further detail.


CPT copyright 2020 American Medical Association. All rights reserved.