In the Part A setting, when billing for PET scans performed to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis, the diagnosis of bone metastasis- C79.51 (Secondary malignant neoplasm of bone) or C79.52 (secondary malignant neoplasm of bone marrow) should be indicated on the claim as per the CMS Internet-Only Manual in addition to the ICD-10 code for the primary malignancy.
PET Scans for the Planning of the Treatment Strategy
CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §60.18, which was issued 11/10/16 (effective for claims with dates of service on or after 02/26/10), is the most current instruction. Palmetto GBA supports the billing requirements as outlined in the CMS Internet-Only Manual which require the following:
Effective for claims with dates of service on or after February 26, 2010, contractors shall accept PET oncologic claims billed with modifier 26 and modifier KX to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis that include the following:
- PI or PS modifier,
- PET or PET/CT CPT® codes (78811, 78812, 78813, 78814, 78815, 78816),
- ICD-10 cancer diagnosis code, AND
- Q0 modifier – Investigational clinical service provided in a clinical research study, are present on the claim.
NOTE: If modifier KX is present on the professional component service, contractors shall process the service as PET NAF-18 rather than PET with FDG.