Oncology & Hematology Coding Alert

Question: We bill the global service for NaF-18 PET scans for bone mets. Are we supposed to add modifier KX to these claims for Medicare?

Answer: No. Because you're reporting the global service, Medicare does not require you to append modifier KX (Requirements specified in the medical policy have been met).

Download this: In Transmittal 2096, CR 7125 (www.cms.gov/transmittals/downloads/R2096CP.pdf), CMS published the guidelines on coding these services (including a helpful chart showing which tracer codes pair with which PET codes).

TC/Global: When you report a global or technical only claim with A9580 (Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries) and an NaF-18 PET service "to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis," the transmittal instructs carriers to process claims that include ALL of the following (in addition to A9580):

• One of these modifiers:
• PI (Positron emission tomography [PET] or PET/ computed tomography [CT] to inform the initial treatment strategy of tumors ...) OR
• PS (Positron emission tomography [PET] or PET/ computed tomography [CT] to inform the subsequent treatment strategy of cancerous tumors ...); AND
• PET or PET/CT CPT code (78811-78816); AND
• ICD-9 cancer diagnosis code; AND
• modifier Q0 (Investigational clinical service provided in a clinical research study).

Professional component: When you use modifier 26 (Professional component) and modifier KX on your PET oncologic claim "to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis," the transmittal instructs carriers to process claims that include ALL of the same items in the bullet list above.

The difference: Code A9580 belongs only on global and technical claims. Carriers will deny professional claims for A9580 because the assumption is that the facility (the entity providing the technical portion of the service) bears the cost of the A9580 agent and should be reimbursed for it.

The presence of modifier KX on the professional claim shows contractors they should "process the service as PET NaF-18 rather than PET with FDG."