Understanding hospital billing for cardiac PET/CT

CMS Relies on hospital-reported data

One of the main points Lawrence highlighted is how CMS uses hospital-reported data to develop payment rates for cardiac PET/CT scans. Specifically, CMS pulls hospital charge data from Medicare claims and applies a "cost-to-charge ratio" to estimate the true costs of procedures. The cost-to-charge ratio helps CMS adjust hospital markups and calculate more accurate procedure costs, which ultimately influence reimbursement rates.

“CMS relies heavily on hospitals to report their costs correctly,” Lawrence said. "It’s crucial for physicians to collaborate with hospital administration to ensure all resource inputs are accounted for in these reports."

Lawrence’s session emphasized the importance of understanding hospital billing and working closely with administrative teams to ensure that CMS receives accurate cost data. Accurate reporting is critical for ensuring fair reimbursement rates, particularly for new technologies like cardiac PET/CT. Physicians and hospitals must also stay informed about evolving coverage policies and legislative reforms, as these factors will continue to shape the landscape of nuclear cardiology and PET/CT reimbursement.

Cardiac PET/CT billing new technology classification

PET/CT codes, especially those for cardiac imaging, are still relatively new. They were introduced in 2020 and are currently categorized under new technology ambulatory payment classifications (APCs). This classification will remain until CMS gathers enough data to place PET/CT codes into standard APC groupings. Despite PET technology being around for over a decade, Lawrence said CMS only recently began collecting comprehensive cost data for cardiac PET/CT, which contributes to the temporary classification.

She explained that hospitals must review and understand these classifications and the accompanying cost data to ensure they’re prepared for changes in reimbursement rates as CMS continues to adjust its payment structures.

Challenges with reimbursement and coverage policies for PET myocardial blood flow

In addition to discussing reimbursement rates, Lawrence touched on the ongoing challenges with coverage for myocardial blood flow analysis through PET. Some private insurers, such as Anthem, continue to classify PET blood flow as experimental and investigational. ASNC is actively working with insurers to advocate for broader coverage, supported by the growing body of clinical studies that highlight the value of PET blood flow in cardiac imaging.

Lawrence encouraged clinicians to stay informed and involved in these discussions, as coverage decisions could directly impact hospital billing and patient care.

Navigating prior authorization reforms

Lawrence also spoke about recent reforms related to prior authorization, a process that often delays patient care. She mentioned promising developments, such as UnitedHealthcare's Gold Card program, which streamlines prior authorizations for certain high-performing physicians. While these reforms have primarily impacted Medicare Advantage plans, Lawrence and ASNC are pushing for broader adoption of similar initiatives across private payers to reduce administrative burdens on healthcare providers.

ASNC's advocacy team put together and posted the document Medicare Reimbursement for Positron Emission Tomography (PET) Scans: The Importance of Charges and Cost-to-charge Ratios, which helps explain the details of cardiac PET billing.

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