PET NaF-18 Clarified, Corrected
The Centers for Medicare & Medicaid Services (CMS) recently clarified billing instructions for positron emission tomography sodium fluoride-18 (PET NaF-18) scans for identifying bone metastasis of cancer in the context of a clinical trial and by correcting applicable codes that can be billed with this service.
Effective Feb. 26, only claims for the technical component (TC) or global service require the radioactive tracer HCPCS Level II code A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries. This billing instruction is found in the Medicare Claims Processing Manual, Pub. 100-04, chapter 13, section 60.3.2.
Professional component (PC) claims should not report A9580 (as it is included in the procedure code), but must contain the P1 Normal healthy patient or P2 Patient with mild systemic disease modifier, the PET or PET with computed tomography (CT) procedure code (78811-78816), the cancer diagnosis code, modifier Q0 Investigational clinical service provided in a clinical research study, as well as modifier 26 Professional component.
Modifier KX Requirements specified in the medical policy have been metalso can be included in PET NaF-18 claims for the PC to differentiate them from PET FDG (fluorodeoxyglucose) claims. Modifier KX is not required on claims submitted to fiscal intermediaries (FIs) or TC and global service claims.
The list of applicable PET or PET with CT CPT® codes that can be used to identify bone metastasis of cancer is changed. CPT® codes 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation and 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation have been removed from this list. Effective Feb. 26, these codes will not be paid to identify bone metastasis with PET NaF-18.
Source: CMS Transmittal 2096, Change Request 7125, issued Nov. 19