PET/CT success follows heavy dose of preparation

Radiologists planning to set up a PET/CT program have a lot to think about, according to a talk at the AHRA Imaging Center Administrators Conference last week in Philadelphia.

They'll need to cover training, documentation, marketing, and billing -- and they'll need to do it properly if they expect their program to be successful, said PET center start-up veteran Lisa McAuley, who discussed the requirements of a successful PET/CT program.

McAuley helped launch the first privately owned PET facility in New England, and has been involved in two other PET start-ups in Vermont and Massachusetts. She is currently pursuing a master's degree in health physics at the University of Massachusetts in Lowell.

It's wise to consider the scope of the PET/CT service before embarking on the program, McAuley said. First, a medical director and clinical supervisor should be appointed to oversee the project.

Clinical standards need to be determined, and utilization standards reviewed and established, she said. Scheduling rules should be set as well. Also important is securing radiologists' department of health (DOH) radioactive materials licensure and PET training experience.

"This (licensure) aspect of getting started may take you the longest amount of time," she said.

Copies of recent continuing medical education documentation for radiologists interpreting PET scans should be provided. The facilities should verify that each physician is qualified to read the nuclear medicine/CT portion of the PET/CT exam. Also make sure that each physician is listed on the facility license, McAuley said.

Then it's time to select your equipment provider, accomplished via a request for proposal (RFP) process. A mobile equipment provider can be selected for short-term use. Also on the agenda: finding an FDG supplier, and determining who will perform the PET/CT studies, as well as who will handle scheduling and billing, she said.

In weighing a short-term lease from a mobile service provider, determine who will supply the techs, which days the service will be offered, and the possibility of extra days, McAuley said. Imaging centers should also examine the contract length, decide whether to limit hours of use of patients per day, and choose the supplier of reading stations.

"Try to negotiate a cost per day, rather than a cost per patient," she said. "If you have it for a day, say a 10- to 12-hour day, you'll probably do eight patients comfortably. It's a lot cheaper to rent by day than by the patient."

Also check on training for techs and physicians, she said. A package plan encompassing technologists, scheduling, billing, and FDG, is also possible as a last resort.

Customers have the option of purchasing a range of scanners, from dual-slice to 16 detectors; if a 16-slice CT system is chosen, also consider using the unit off-hours, McAuley said. The budget and personnel requirements for the scanner need to be determined, as well any plans to use the system for cardiac and RadOne applications.

During site planning, the PET/CT equipment provider should submit written acceptance of the facility site plan that covers the exact location of the coach during imaging, as well as electrical, cooling, and pad (site) requirements, McAuley noted. PET/CT suite shielding and scanner siting issues are of vital concern.

"The biggest thing to consider, whether you have a mobile or fixed site, is where to put your patient bathroom," she said. "Urine (from a patient who has undergone PET/CT) is radioactive; you don't want these facilities near pregnant women and children."

Training and documentation

The PET equipment provider and FDG supplier should provide offsite training for radiologist interpretation, and onsite training or provision of billing and scheduling personnel, McAuley said. A mobile PET/CT provider should provide onsite training or provision of PET technologists.

"Get these in writing as part of the contract," she said.

Scheduling and billing personnel should also receive training, often provided by a consultant, equipment provider, or FDG supplier, McAuley said. Training needs to cover documentation for billing and reimbursement, as well as the timing and scheduling of FDG dose arrival and patient readiness, she said.

Also develop a procedure for the ordering, receipt, and disposal of FDG. A written agreement with the mobile PET/CT provider should be secured in compliance with state regulatory requirements, and must be documented properly by PET technologists, she said.

Radiation safety remains the responsibility of the facility and its radiation safety officer (RSO), she said. State regulations often require an authorized user onsite when dealing with radioactive materials. Consider all aspects of moving and care of the injected FDG patient, with the use of bathroom facilities and area monitoring overseen by the RSO.

PET technologists need to document radiation safety procedures, with the RSO overseeing the process. The procedures are similar to those for nuclear medicine exams, and require a strict written consent policy for women of childbearing age and a strict written dose policy for pediatric patients, she said.

Operators should be aware of the overall exposure to nuclear medicine technologists performing PET/CT exams, particularly if they perform high-dose Cardiolite procedures, she said. Technologists performing PET/CT studies should be rotated once they are completely trained.

"Monitor patient waiting areas, injection rooms, and bathroom facilities," McAuley said. "Consider lead lining in areas where personnel spend the most time."

The licensure of PET/CT technologists is an evolving issue, she said. Many states are now approving in-house CT training programs for PET technologists, while the Nuclear Medicine Technology Certification Board (NMTCB) offered a PET specialty exam for practicing PET technologists in September. The American Registry of Radiologic Technologists (ARRT) has approved an augmented CT exam for nuclear medicine technologists in 2005, and the NMTCB will offer an augmented PET specialty exam to RTs and RTTs in 2005.

Other issues for prospective PET/CT sites to consider include image management and reimbursement requirements. Sites need to determine how images will be saved and transferred to the reading station, McAuley said. Also attain insurance carrier contracts for PET/CT services early on in the project, and understand Medicare requirements for reimbursement.

"Most carriers require prior authorization for PET/CT to be reimbursed," she said. "The CT portion of the PET exam is not reimbursed when used as attenuation correction for PET."

Develop a protocol and procedure manual, and plan the handling of patient workload and throughput. Technologists should be allowed to manage patients and throughput, McAuley said.

"It's imperative that workload always revolves around the FDG arrival," she said. "There's no acceptable waiting time. You lose 10% of your dose every 15 minutes."

Of course, the interpretation and report generation process should also be defined, McAuley said.


Another key to success for starting a new PET/CT program is marketing. A physician referral marketing plan should be created, including the development of a contact list such as referring physicians, group practices/oncology centers, and insurance carriers, McAuley said. Other ideas include an open house and facility tour, as well as a media release announcing the opening to the community.

Formulate an ongoing physician referral education and marketing plan, including a grand rounds or tumor board presentation, she said. A PET/CT exam information packet can also be distributed to referring offices.

Billing PET/CT

As for billing, specific CPT or HCPCS codes are not currently available for a combined PET/CT scan, but it's anticipated that PET and PET/CT CPT codes will be available in January 2005, McAuley said.

Billing for PET/CT payment, when a diagnostic CT scan is performed in addition to the PET scan, is considered reasonable if both scans are ordered by the patient's referring physicians, indicated, and done at a diagnostic level quality considered standard of care, she said.

"Be sure to obtain appropriate preauthorizations for the separate PET and CT scan when appropriate," McAuley said. "The procedure should be coded separately using the appropriate HCPCS or CPT code for PET, and the appropriate CPT code for the diagnostic CT scan."

By Erik L. Ridley staff writer
October 14, 2004

Related Reading

Changing market for PET brings challenges and opportunities, September 30, 2004

CMS to cover PET for Alzheimer's, September 17, 2004

PET/CT shows potential for coronary artery disease assessment, August 13, 2004

Radiologists install PET/CT despite community opposition, July 22, 2004

PET procedure volume to surge, July 21, 2004

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