(Medicare Claims Processing Manual)

Hospitals subject to OPPS should report the following C codes in place of the above HCPCS codes as follows:    MRA of chest 71555: C8909  C8911  MRA of abdomen 74185: C8900  C8902   MRA of peripheral vessels of lower extremities 73725: C8912  C8914   For claims with dates of service on or after July 1, 2003, coverage under this benefit has been expanded for the use of MRA for diagnosing pathology in the renal or aortoiliac arteries. The following HCPCS code should be used to report this expanded coverage of MRA:    MRA, pelvis, with or without contrast material(s) 72198, 72198- 26, 72198- TC  Hospitals subject to OPPS report the following C codes in place of HCPCS code 72198:    MRA, pelvis, with or without contrast material(s) 72198: C8918 -  C8920  NOTE:   Information regarding the claim form locator that corresponds to the HCPCS code and a table to crosswalk its CMS -1450 form locator to the 837 transaction is found in Chapter 25.   40.1.3 - Special Billing Instructions for RHCs and FQHCs  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  Independent RHCs and free -standing FQHCs bill under bill type 71X and 73X for the professional component utilizing revenue codes 520 and 521 as appropriate.  HCPCS coding is not required.  The technical component is outside the scope of the RHC/FQHC benefit.  The provider of the technical service bills using the ASC X12 837 professional claim format or on Form CMS -1500.  The technical component for a provider based RHC/FQHC is typically furnished by the provider.  The provider of that service bills under bill type 13X or 85X as appropriate using its outpatient provider number (not the RHC/FQHC provider number since these s ervices are not covered as RHC/FQHC services).  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for radiology services.   40.1.4  Payment Requirements (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  For claims with dates of service on and after February 24, 2011, the following diagnosis code and modifier shall be reported on MRI claims for beneficiaries with implanted PMs, that are outside FDA -approved labeling for use in an MRI environment (in a Medi care- approved clinical study):    Appropriate MRI code   Q0 modifier   Condition code 30 (for institutional claims)   If ICD -9-CM is applicable  o ICD-9 code V70.7-  Examination of participant in clinical trial (for institutional claims)  o ICD-9 code V45.02 (automatic implantable cardiac defibrillator) or  o ICD-9 code V45.01 (cardiac pacemaker)    If ICD -10-CM is applicable   Z00.6 -  Encounter for examination for normal comparison and control in clinical research program   Z95.810 -  Presence of automatic (implantable) cardiac defibrillator or   Z95.0 -  Presence of cardiac pacemaker   For claims with dates of services on and after July 7, 2011, the following codes shall be reported on MRI claims for beneficiaries with implanted PMs that have FDA -approved labeling for use in an MRI environment:    Appropriate MRI code   KX modifier   If ICD -9-CM is applicable  o ICD-9 code V45.01 (cardiac pacemaker)   If ICD- 10-CM is applicable  o ICD-10 code Z95.0 (cardiac pacemaker)   Payment is as follows:   Professional claims (practitioners and suppliers) -   based on the Medicare Physician Fee Schedule (MPFS)    Inpatient (11x) -  Prospective payment system (PPS), based on the diagnosis -related group    Hospital outpatient departments (13x) -  Outpatient PPS, based on the ambulatory payment classification    Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) (71x/77x) -  All-inclusive rate, professional component only, based on the visit furnished to the RHC/FQHC beneficiary to receive the MRI.  The technical component is outside the scope of the RHC/FQHC benefit.  Therefore the provider of the technical service bills their A/B MAC (B) on the ASC X12 837 professional claim format or hardcopy Form CMS -1500 and payment is made under the MPFS.    Critical access hospitals (CAHs) (85x)    o For CAHs that elected the optional method of payment for outpatient services, the payment for technical services would be the same as the CAHs that did not elect the optional method -  Reasonable cost.   o The A/B MAC (A) pays the professional component at 115% of the MPFS.  Deductible and coinsurance apply.   40.2  Medicare Summary Notices (MSN), Reason Codes, and Remark Codes (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02- 10-17)  The A/B MAC denies MRI line items on claims when billed with the appropriate MRI code and a diagnostic code for cardiac pacemaker if modifier KX is not present.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 188  RARC: N/A  MSN: 21.8  The A/B MAC denies MRI line items that do not include all of the following line items:    An appropriate MRI code,   If ICD -9-CM is applicable, ICD -9 code V45.02 (automatic implantable cardiac defibrillator) or ICD-9 code V45.01 (cardiac pacemaker),    ICD-10-CM is applicable, ICD -10 code Z95.810 (automatic implantable cardiac defibrillator)or ICD-10 code Z95.0 (cardiac pacemaker),    Modifier Q0,    If ICD -9-CM is applicable, ICD -9 code V70.7 Examination of participant in clinical trial (for institutional claims only)or    If ICD -10-CM is applicable, ICD -10 code Z00.6  Examination of participant in clinical trial (for institutional claims only), and    Condition code 30 (for institutional claims only).   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 272  RARC: N386  MSN: 21.21  50 - Nuclear Medicine (CPT 78000 - 79999)  (Rev. 1, 10- 01-03)  50.1 - Payments for Radionuclides  (Rev. 1, 10- 01-03)  The TC RVUs for nuclear medicine procedures (CPT codes 78XXX for diagnostic nuclear medicine, and codes 79XXX for therapeutic nuclear medicine) do not include the radionuclide used in connection with the procedure.  These substances are separately billed under codes A4641 and A4642 for diagnostic procedures, and code 79900 for therapeutic procedures and are paid on a By Report basis depending on the substance used.  In addition, CPT code 79900 is separately payable in connection with certain clinical brachytherapy procedures.  (See 70.4 for brachytherapy procedures).  50.2 - Stressing Agent  (Rev. 1, 10- 01-03)  A/B MACs (B) must make separate payment under code J1245 for pharmacologic stressing agents used in connection with nuclear medicine and cardiovascular stress testing procedures furnished to beneficiaries in settings in which TCs are payable.  Such an agen t is classified as a supply and covered as an integral part of the diagnostic test.  However, A/B MACs (B) pay for code J1245 under the policy for determining payments for incident to drugs.  See Chapter 17 for payment for drugs.   50.2.1 - A/B MAC (A) Payment for IV Persantine  (Rev. 1, 10- 01-03)  The A/B MACs (A) pay drug IV Persantine based on the drug pricing methodology when used in conjunction with nuclear medicine and cardiovascular stress testing procedures furnished to SNF outpatients.  Separate drug pricing methodology payments for IV Persa ntine is made in addition to payments made for the procedure.  SNFs bill HCPCS code J1245 (injection, dipyridamole, per 10 mg.) with revenue code 0636.   50.2.2 - A/B MAC (A) Payment for Adenosine  (Rev. 1, 10- 01-03) SNF -533.3  The drug adenosine is paid based on the drug payment methodology when used as a pharmacologic stressor for other diagnostic testing.  Separate based payment for adenosine will be made in addition to payments made for the procedure for SNF Part B patients.  When billing for adenosine, HCPCS code J0150 (Injection, adenosine, 6 mg.) should be reported with revenue code 0636.  50.3 - Application of Multiple Procedure Policy (CPT Modifier - 51) (Rev. 1, 10- 01-03)  A/B MACs (B) must apply the multiple procedure reduction to the following nuclear medicine diagnostic procedures: codes 78306, 78320, 78802, 78803, 78806, and 78807.  50.4 - Generation and Interpretation of Automated Data  (Rev. 1, 10- 01-03)  Payment for CPT codes 78890 and 78891 is bundled into payments for the primary procedure.   60 - Positron Emission Tomography (PET) Scans   General Information  (Rev. 1833; Issued:  10- 16-09; Effective Date:  04 -03-09; Implementation Date:  10- 30-09)  Positron emission tomography (PET) is a noninvasive imaging procedure that assesses perfusion and the level of metabolic activity in various organ systems of the human body. A positron camera (tomograph) is used to produce cross -sectional tomographic image s which are obtained by detecting radioactivity from a radioactive tracer substance (radiopharmaceutical) that emits a radioactive tracer substance (radiopharmaceutical FDG) such as 2 [F -18] flouro -D-glucose FDG, that is administered intravenously to the patient.   The Medicare National Coverage Determinations (NCD) Manual, chapter 1, 220.6, contains additional coverage instructions to indicate the conditions under which a PET scan is performed.   A.   Definitions   For all uses of PET, excluding Rubidium 82 for perfusion of the heart, myocardial viability and refractory seizures, the following definitions apply: