CMS Pub. 100-04, ch. 13, § 60.18

Identify Bone Metastasis of Cancer Effective for Claims With Dates of

Services on or After February 26, 2010

(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)

• Billing Changes for A/B MACs (A and B)

Effective for claims with dates of service on and after February 26, 2010, contractors

shall pay for NaF-18 PET oncologic claims to inform of initial treatment strategy (PI)

or subsequent treatment strategy (PS) for suspected or biopsy proven bone metastasis

ONLY in the context of a clinical study and as specified in Pub. 100-03, section

220.6. All other claims for NaF-18 PET oncology claims remain non-covered.

• Medicare Summary Notices, Remittance Advice Remark Codes, and

Claim Adjustment Reason Codes

Effective for claims with dates of service on or after February 26, 2010, contractors

shall return as unprocessable NaF-18 PET oncologic claims billed with modifier TC

or globally (for A/B MACs (A) modifier TC or globally does not apply) and

HCPCS A9580 to inform the initial treatment strategy or subsequent treatment

strategy for bone metastasis that do not include ALL of the following:

• PI or PS modifier AND

• PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816)

AND

• Cancer diagnosis code AND

• Q0 modifier - Investigational clinical service provided in a clinical

research study, are present on the claim.

NOTE: For institutional claims, continue to include ICD-10 diagnosis code

Z00.6 and condition code 30 to denote a clinical study.

The contractor shall use the following remittance advice messages and associated

codes when returning claims under this policy. This CARC/RARC combination is

compliant with CAQH CORE Business Scenario Two

Group Code:

CO CARC: 4

RARC: MA130

MSN: N/A

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 AND

• PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816)

AND

• 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.

Contractors shall also return as unprocessable NaF-18 PET oncologic professional

component claims (i.e., claims billed with modifiers 26 and KX) to inform the

initial treatment strategy or subsequent treatment strategy for bone metastasis

billed with HCPCS A9580.

The contractor shall use the following remittance advice messages and associated

codes when returning claims under this policy. This CARC/RARC combination is

compliant with CAQH CORE Business Scenario Two.

Group Code:

CO

CARC: 4

RARC: MA130

MSN: N/A

NOTE: Effective for claims with dates of service on or after 12/15/2017, HCPCS code

A9580 (NaF-18) is nationally non-covered.