Local Coverage Article Billing and Coding

Billing and Coding: PET Scan Claims to Identify Bone Metastasis of Cancer

A54735

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Contractor Information

Article Information

General Information

Article ID
A54735
Article Title
Billing and Coding: PET Scan Claims to Identify Bone Metastasis of Cancer
Article Type
Billing and Coding
Original Effective Date
11/12/2015
Revision Effective Date
10/10/2019
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §60.18

Article Guidance

Article Text

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.

Coding Information

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
78811 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK)
78812 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH
78813 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY
78814 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK)
78815 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH
78816 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY

CPT/HCPCS Modifiers

Group 1

(5 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
26 PROFESSIONAL COMPONENT: CERTAIN PROCEDURES ARE A COMBINATION OF A PHYSICIAN COMPONENT AND A TECHNICAL COMPONENT. WHEN THE PHYSICIAN COMPONENT IS REPORTED SEPARATELY, THE SERVICE MAY BE IDENTIFIED BY ADDING THE MODIFIER -26 TO THE USUAL PROCEDURE NUMBER OR THE SERVICE MAY BE REPORTED BY USE OF THE FIVE DIGIT MODIFIER CODE 09926.
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET
PI POSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORM THE INITIAL TREATMENT STRATEGY OF TUMORS THAT ARE BIOPSY PROVEN OR STRONGLY SUSPECTED OF BEING CANCEROUS BASED ON OTHER DIAGNOSTIC TESTING
PS POSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORM THE SUBSEQUENT TREATMENT STRATEGY OF CANCEROUS TUMORS WHEN THE BENEFICIARY'S TREATING PHYSICIAN DETERMINES THAT THE PET STUDY IS NEEDED TO INFORM SUBSEQUENT ANTI-TUMOR STRATEGY
Q0 INVESTIGATIONAL CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN APPROVED CLINICAL RESEARCH STUDY

ICD-10-CM Codes that Support Medical Necessity

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/10/2019 R5

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under Article Title changed the title from “Billing Requirements for PET Scan Claims to Identify Bone Metastasis of Cancer” to “Billing and Coding: PET Scan Claims to Identify Bone Metastasis of Cancer”. Under CMS National Coverage Policy added CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §60.18. Under Article Text subheading PET Scans for the Planning of the Treatment Strategy revised the first paragraph to reflect Change Request 7125 becoming manualized. Under CPT/HCPCS Modifiers Group 1: Codes added modifiers 26, KX, PI, PS, and Q0. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 codes C79.51 and C79.52.

10/11/2018 R4

Under Article Text formatting was corrected throughout the section.

02/26/2018 R3 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
10/19/2017 R2

Under Article Text the issued date was changed from 04/02/15 to 11/10/16 and the verbiage under NOTE, was revised to read “If modifier KX is present on the professional component service, contractors shall process the service as PET NAF-18 rather than PET with FDG." Under CPT/HCPCS Codes, the following CPT codes were added: 78811, 78812, 78813, 78814, 78815, and 78816.

11/17/2016 R1 Under Article Text –PET Scans for the Planning of the Treatment Strategy for the third bullet revised the verbiage to delete the following “ICD 9 (currently ICD 10 effective 10/01/2015) …” and added "ICD-10".

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
10/01/2019 10/10/2019 - N/A Currently in Effect You are here
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Keywords

  • PET Scan
  • PET Scan for Bone Metastasis
  • Bone Metastasis