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.

Clarification

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.

Correction

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

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3 Responses to “PET NaF-18 Clarified, Corrected”

  1. Susan Bologna says:

    The above article on PET scans states the professional component claims must contain the P1 (normal healthy patient) or P2 (patient with mild systemic disease) modifier. I was unable to find that statement in the IOM and was wondering if the article should be referring to modifiers PI (initial treatment strategy) and PS (subsequent treatment strategy)?

  2. Jonathan Berg, M.S., R.T.(R)(CT), CNMT, PET says:

    I agree with Susan’s comments – I believe the author of this article has mistaken P1 and P2 with PI and PS – reference the transmittal noted below the article.

  3. Valleska A. says:

    I agree with Susan, also it doesn’t say that in order that Medicare pay for this exam it has go under a program called National Oncology Pet Registry (NOPR) and a Pre-PET Form must be completed by the referring physician and returned to the PET facility prior to the patient’s PET scan. The case is eligible for CMS reimbursement only if the Pre-PET Form is completed and returned to the PET facility prior to the PET scan and the Post-PET Form is completed and returned within 30 days of the PET scan. We need to bill Medicare with modifier PS or PI and Q0.

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