Good documentation is the key to cardiac PET prior authorizations
As more nuclear cardiology programs add positron emission tomography (PET) imaging, documentation is key if you want to prevent issues with prior authorizations and billing submissions.
Erin R. Stevens, CNMT, NCT, director of nuclear medicine at Oregon Heart Center, spoke on this topic in a business session at the 2024 American Society of Nuclear Cardiology (ASNC) meeting. In an interview with Cardiovascular Business, she said training physicians for what is needed in cardiac PET documentation will go a long way toward preventing payment and prior authorization bottlenecks.
When Oregon Heart Center became one of the first programs in the state to offer for PET five years ago, she said they ran into a number of issues. With experience, however, they learned how to avoid the problems.
"We do run into the occasional denial or needing more information for pre-auth, but my suggestion for that is to make sure you have your physicians are fully trained in PET documentation. Documentation is a huge thing for prior authorization," Stevens explained.
Sometimes, she said, information that is taken for granted as common knowledge can lead to a denial and cause frustration. She pointed to the example of the need to use pharmacologic stress when using rubidium-82 generators because the radiotracer only has a 75-second half life, which does not allow time for exercise stress test.
"You can't just say a patient can't walk on a treadmill, you have to say why they can't walk on a treadmill. So making sure that everything is documented correctly and then having the correct ICD-10 codes is important," Stevens said.
She said Medicare is more forgiving with PET than private insurance companies, as long as you have the proper ICD-10 codes
"If you're going to start, most places will start their program with Medicare patients because you don't need prior auth for it. But, having the correct ICD 10 codes is key for that. So you need to get the physicians trained on those codes. You can't use chest pain or dyspnea on exertion as you could for SPECT. Medicare wants other forms of angina equivalent for patients that don't have history at all, or are coming in with symptoms. Those are important codes to know because they will not pay for it if you don't have those codes in there," she explained.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com