(Medicare Claims Processing Manual)

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 April 3, 2009, through June 10, 2013, contractors shall return as unprocessable/return to provider FDG PET claims billed to inform initial treatment strategy or subsequent treatment strategy  when performed under CED without one of the PET/PET/CT CPT codes listed in subsection C. above AND modifier PI OR modifier PS AND a cancer diagnosis code AND modifier Q0/Q1.   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 April 3, 2009, contractors shall deny claims with ICD -9/ICD -10 diagnosis code 185/C61 for FDG PET imaging for the initial treatment strategy  of patients with adenocarcinoma of the prostate.   For dates of service prior to June 11, 2013, contractors shall also deny  claims for FDG PET imaging for subsequent treatment strategy  for tumor types other than breast, cervical, colorectal, esophagus, head and neck (non- CNS/thyroid), lymphoma, melanoma, myeloma, non- small cell lung, and ovarian, unless the FDG PET is provided under CED (submitted with the Q0/Q1 modifier) and use the following messages:   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: PR (if claim is received with a GA modifier) otherwise CO  CARC: 50  RARC: N/A  MSN: 15.4  Effective for dates of service on or after June 11, 2013, contractors shall use the following messages when denying claims in excess of three for PET FDG scans for subsequent treatment strategy when the KX modifier is not included, identified by CPT codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier PS, HCPCS A9552, and the same cancer diagnosis code.   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: PR (if claim is received with a GA modifier) otherwise CO  CARC: 96  RARC: N435  MSN: 23.17  60.17  Billing and Coverage Changes for PET Scans for Cervical Cancer Effective for Services on or After November 10, 2009  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02- 10-17)  A.  Billing Changes for A/B MACs (A and B)   Effective for claims with dates of service on or after November 10, 2009, contractors shall accept FDG PET oncologic claims billed to inform initial treatment strategy; specifically for staging in beneficiaries who have biopsy- proven cervical cancer when t he beneficiarys treating physician determines the FDG PET study is needed to determine the location and/or extent of the tumor as specified in Pub. 100- 03, section 220.6.17.  EXCEPTION:  CMS continues to non- cover FDG PET for initial diagnosis of cervical cancer related to initial treatment strategy.   NOTE:   Effective for claims with dates of service on and after November 10, 2009, the Q0 modifier is no longer necessary for FDG PET for cervical cancer.   B.  Medicare Summary Notices, Remittance Advice Remark Codes, and Claim   Adjustment Reason Codes  Additionally, contractors shall return as unprocessable /return to provider for FDG PET for cervical cancer for initial treatment strategy billed without the following:  one of the PET/PET/ CT CPT codes listed in 60.16 C above AND modifier PI AND a cervical cancer diagnosis code.   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  60.18  Billing and Coverage Changes for PET (NaF- 18) Scans to 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 metastas is 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.   60.19  Local Coverage Determination for PET Using New, Proprietary Radiopharmaceuticals for their FDA -Approved Labeled Indications for Oncologic Imaging Only  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02- 10-17)  Effective for dates of service on or after March 7, 2013, local Medicare Administrative Contractors (MACs) may determine coverage within their respective jurisdictions for positron emission tomography (PET) using radiopharmaceuticals for their Food and Drug Administration (FDA) approved labeled indications for oncologic imaging.  When the local MAC determines that a claim is noncovered, the claim is denied:   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: PR (if claim is received with a GA modifier) otherwise CO  CARC: 167  RARC: N/A  MSN: 15.4  70 - Radiation Oncology (Therapeutic Radiology)  (Rev. 1, 10- 01-03)  70.1 - Weekly Radiation Therapy Management (CPT 77419 - 77430)  (Rev. 1, 10- 01-03)  A/B MACs (B) must pay for a physicians weekly treatment management services under code 77427.  Billing entities must indicate on each claim the number of fractions for which payment is sought.  A weekly unit of treatment management is equal to five fractions or treatment sessions.  A week for the purpose of making payments under these codes is comprised of five fractions regardless of the actual time period in which the services are furnished.  I t is not necessary that the radiation therapist personally examine the patient during each fraction for the weekly treatment management code to be payable.  Multiple fractions representing two or more treatment sessions furnished on the same day may be counted as long as there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on different days.  If, at the final billing of the treatment course, there are three or four fractions beyond a multiple of five, those three or four fractions are paid for as a week.  If there are one or two fractions beyond a multiple of five, payment for these services is considered as having been made through prior payments.  EXAMPLE:  18  fractions  =   4 weekly services  62  fractions  = 12 weekly services  8  fractions  =   2 weekly services  6  fractions  =   1 weekly service   If billings have occurred which indicate that the treatment course has ended (and, therefore, the number of residual fractions has been determined), but treatments resume, adjust A/B MAC (B) payments for the additional services consistent with the above policy.  EXAMPLE:  8 fractions = payment for 2 weeks  2 additional fractions are furnished by the same physician.  No additional Medicare payment is made for the 2 additional fractions. A.  SNF Treatment Management Delivery Services   A SNF may not bill weekly treatment management services for its outpatients (codes 77419, 77420, 77425, 77430, and 77431).  Instead, the SNF should bill for radiation treatment delivery (codes 77401 -  77404, 77406 -  77409, 77411 -  77414, and 77416).  Also,  SNFs bill for therapeutic radiology port film (code 77417), which was previously a part of the weekly services.  They enter the number of services in the units field.   70.2 - Services Bundled Into Treatment Management Codes  (Rev. 4267, Issued: 03- 27-19, Effective: 01 -01-19, Implementation: 03- 25-19)