RETIRED LCD Reference Article Billing and Coding Article

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

A54735

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
Retired

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54735
Original ICD-9 Article ID
Not Applicable
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
05/10/2023
Retirement Date
05/10/2023
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
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
N/A

CPT/HCPCS Modifiers

Group 1

(5 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
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
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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.

Code Description
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.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
05/10/2023 R6

This article is being retired because the information in this article is not up to date with 21st Century Cures requirements, is not supported by a Local Coverage Determination (LCD) and does not comply with current requirements.

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".
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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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
05/10/2023 10/10/2019 - 05/10/2023 Retired You are here
10/01/2019 10/10/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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