PROCEDURE CODE 78608, 78609, 78811 and traced code

CMS directs that the evidence is currently not sufficient to determine that the results of the use of NaF-18 PET imaging to identify bone metastases or suspected boney metastases of cancer would improve health outcomes of beneficiaries with cancer. Therefore, this use is not considered reasonable and necessary.

However, CMS further directs that the current evidence is sufficient to determine that this imaging, to inform initial treatment strategy or subsequent treatment for suspected or biopsy proven bone metastasis is covered, through CED, ONLY in the context of clinical study; this is effective for claims with dates of service on and after February 26, 2010. Please review the CMS documents for the complete information regarding acceptable clinical studies. All other uses of NaF-18 PET are non-covered.

Reporting Guidelines

Bone metastasis of cancer, NaF-18 PET: Based on CR 6861 and CR 7125, for claims with dates of service on and after February 26, 2010, HCPCS A9580, sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries, shall be used for all NaF-18 PET oncology claims received on or after July 6, 2010.

The procedure codes listed for PET scans represent the global service. Therefore, providers performing only the technical or professional component of the test should use modifier TC or 26, respectively.

NaF-18 PET scans performed under CED should be reported with the Q0 modifier (number “0”, not letter “O”). For institutional claims, ICD-9 CM diagnosis code V70.7 and condition code 30 should also be reported.

For Part A claims for all PET scans, use an additional ICD-9-CM code when coding involves a V code.

PET with concurrently acquired CT is reported with procedure codes 78814-78816 as appropriate. These codes should not be reported for PET scans performed on a non-hybrid scanner.

If a PET scan is obtained and, on the same date of service, diagnostic CT scan(s) are obtained at a separate session, then both the PET scan and the CT scan(s) may be coded individually. If a PET/CT study is performed concurrently on a hybrid PET/CT scanner and an additional diagnostic CT scan is also obtained non-concurrently, it is appropriate to code the PET/CT scan and the diagnostic CT scan(s) separately (whether the diagnostic CT scans are performed on a hybrid PET/CT scanner or on a dedicated CT scanner). To further clarify this, the CT component of a PET/CT scan is for concurrently obtained CT scans for attenuation correction and localization and does not include any additional diagnostic CT studies that may be requested.

When a diagnostic CT scan is performed concurrently with a PET scan, the appropriate PET scan and the appropriate diagnostic CT code may be reported. If a medically necessary diagnostic CT is performed non-concurrently with a PET/CT scan, either on the PET/CT scanner or on an independent CT scanner, the appropriate PET/CT procedure code and the diagnostic CT study(s) code may be reported.

Procedure code 78609 is a non-covered service.

HCPCS code A4641 is not an applicable tracer for PET scans.

The applicable PET HCPCS/Procedure code and the applicable tracer HCPCS/Procedure code should be reported on the same claim.

Only claims for the technical component (TC) or global service require the radioactive tracer, HCPCS A9552 or A9580. Claims for the professional component (PC) do not require the tracer but must contain the appropriate –PI or –PS modifier, PET/with computed tomography (CT) HCPCS procedure code, diagnosis code and the 26 modifier for FDG PET studies and NaF-18 PET scans.

The Q0 modifier should also be added for the NaF-18 PET scans for the professional component.
• PI modifier – initial treatment strategy
• PS modifier – subsequent treatment strategy
• 26 modifier – professional component
• Q0 modifier – provided under Coverage with Evidence Development (CED)