Coverage for sodium fluoride F 18 (18F NaF) PET imaging is included under the Coverage with Evidence Development (CED) to: “assist initial antitumor treatment planning or to guide subsequent treatment strategy by the identification, location and quantification of bone metastases in beneficiaries in whom bone metastases are strongly suspected based on clinical symptoms or the results of other diagnostic studies.”1
The National Oncologic PET Registry (NOPR) enrolls patients for 18F NaF Bone PET studies and reimburses 18F NaF PET scans when the beneficiary is enrolled in, and the 18F NaF PET provider and treating physician are participating in, the NOPR clinical study.
For more information, visit the NOPR website:
Taken from Medicare Claims Processing Manual revised July 20072:
Medicare covered PET procedures for bone scans should be reported using CPT® codes as well as the applicable Healthcare Procedure Coding System (HCPCS) Level II code for the radiopharmaceutical. According to CMS, 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 strategy or subsequent treatment strategy for bone metastasis that include the following:
PI or PS modifier AND
PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816) AND
ICD-9 cancer diagnosis code AND
Q0 modifier – Investigational clinical service provided in a clinical research study, are present on the claim.
If modifier KX is present on the professional component service, Contractors shall process the service as 18F NaF PET rather than 18F FDG PET.
Contractors shall also return as unprocessable 18F NaF PET oncologic professional component claims (e.g., claims billed with modifiers 26 and KX).
Medicare National Coverage Determinations Manual Chapter 1, Part 4 Section 220.6.19 Positron Emission Tomography (NaF-18 PET) to Identify Bone Metastases of Cancer (Effective February 26, 2010) (Rev. 119, Issued 03-26-10, Effective 02-26-10, Implementation 07-06-10) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_part4.pdf
Medicare Claims Processing Manual revised July 2007, Chapter 13, Section 60.18 Billing and Coverage Changes for PET (NaF-18) Scans to Identify Bone Metastases of Cancer Effective for Claims with Dates of Services on or After February 26, 2010 (Rev. 2096, Issued: 11-19-10, Effective: 02-26-10, Implementation: 02-22-11) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf