Transcript Slide 1
Sample Hospital Billing NaF-PET/CT Study - skull vertex to feet Medicare / Managed Medicare Initial Treatment Strategy (Breast Cancer) Hospital Outpatient Setting Any Hospital One Hospital Road Any City, Any State 00010 XXXXXXXXX 66-66678 Siegel, Bonnie 01/17/1934 02/8/2011 131 02/8/2011 123 Any Street Any City Any State USA F 222222 30 Form Locator 24-30: Managed Medicare Enter the condition “30” Qualifying Clinical Submit NaF claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NaF NOPR claims 0404 NOPR PET/CT Whole Body 0343 Sodium Fluoride -NaF per dose 78816 Q0 PI A9580 Trials Non-research services provided to all patients, including managed care enrollees enrolled in a Qualified Clinical Trial. 02/8/2011 1 XXXX.XX 02/8/2011 1 XXX.XX Form Locator 46: Enter the number of units based on the CPT or HCPCS code description Form Locator 42: Enter revenue codes. 0404 PET Procedures 0343 Diagnostic Radiopharmaceutical Form Locator 67 & 68: Form Locator 44: Enter CPT or HCPCS code for procedures and radiopharmaceuticals or drug. 78816 PET/CT Whole Body A9580 NaF, diagnostic, per study dose, up to 30 millicuries Q0 (zero) Investigational clinical service provided in a clinical research study that is in an approved clinical research study PI PET or PET/CT to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing Enter ICD-9-CM code for principle diagnosis in FL 67. 174.9 Breast (female), unspecified 1122431 Enter NOPR Identifier in FL 68 V70.7 Exam of Participants in Clinical Trials Bonnie Siegel 1749 123-45-6789 Medicare XXXXXXXXX V707 CPT codes, descriptions and 2-digit numeric modifiers only are copyright, 2009 AMA. All rights Reserved Educational Materials Prepared for National Oncologic PET Registry Revised: February 2011 www.cancerPETRegistry.org Sample Physician Billing NaF-PET/CT Study - skull vertex to feet Medicare/Managed Medicare Initial Treatment Strategy (Breast Cancer) Hospital Outpatient Setting Managed Medicare Submit claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NaF NOPR claims. 123-45-6789 X Siegel, Bonnie 01 17 1934 123 Any Street AS Siegel, Bonnie 123 Any Street X Any City 00010 X Any City X xxx xxx xxxx xxx xxx xxxx 00010 Form Locator 21 & 24E: X Enter ICD-9-CM code for principle diagnosis in FL 21. Enter the line number corresponding to the procedure in FL 24E X 01 17 1934 X Medicare X 174.9 Breast (female), unspecified Signature On File Form Locator 24G: Enter the number of units based on the CPT or HCPCS code description (NOTE some payers require this field blank for use with Q0 (Zero.) 174.9 02 8 2011 02 8 2011 22 78816 26 Q0 PI KX 1 XXXX.XX 1 Form Locator 24D & 19: Enter CPT or HCPCS code for procedures interpreted by the physician In the hospital outpatient setting 78816 PET/CT Whole Body 26 modifier, Professional Component Q0 (zero) Investigational clinical service provided in a clinical research study that is in an approved clinical research study XXX.XX PI PET or PET/CT to inform the initial treatment strategy of tumors that are biopsy KX Requirements specified in the medical policy have been met proven or strongly suspected of being cancerous based on other diagnostic testing FL 19 In order to facilitate coverage and payment list description as NOPR Patient (Note some contractors require this field remain blank, if you experience difficulty try leaving field blank. XXXXXXX CPT codes, descriptions and 2-digit numeric modifiers only are copyright, 2009 AMA. All rights Reserved Educational Materials Prepared for National Oncologic PET Registry Revised: February 2011 www.cancerPETRegistry.org Sample Physician Office Medicare/Managed Medicare NaF-PET/CT Study - skull vertex to feet Initial Treatment Strategy (Breast Cancer) Non-Hospital Technical Managed Medicare Submit claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NOPR claims with date of service on or after 4/3/2009. 123-45-6789 X Siegel, Bonnie 01 17 1934 123 Any Street AS Siegel, Bonnie 123 Any Street X Any City 00010 X Any City X xxx xxx xxxx xxx xxx xxxx 00010 X Form Locator 21 & 24E: X Enter ICD-9-CM code for principle diagnosis in FL 21. Enter the line number corresponding to the procedure in FL 24E 174.9 Breast (female), unspecified X 01 17 1934 X Medicare Signature On File Form Locator 24G: Enter the number of units based on the CPT or HCPCS code description (NOTE some payers require this field blank for use with Q0 (Zero.) 174.9 02 8 2011 02 8 2011 11 78816 TC Q0 PI 1 XXXX.XX 1 02 8 2011 02 8 2011 11 A9580 1 XXX.XX 1 Form Locator 24D & 19: Enter CPT or HCPCS code for technical procedures performed by the PET center. 78816 PET/CT Whole Body A9580 NaF, Sodium Fluoride, diagnostic, per study dose, up to 30 millicuries TC modifier, Technical Component Q0 (zero) Investigational clinical service provided in a clinical research study that is in an approved clinical research study XXX.XX PI PET or PET/CT to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing FL 19 In order to facilitate coverage and payment list description as NOPR Patient (Note some contractors require this field remain blank, if you experience difficulty try leaving field blank. XXXXXXX CPT codes, descriptions and 2-digit numeric modifiers only are copyright, 2009 AMA. All rights Reserved Educational Materials Prepared for National Oncologic PET Registry Revised: February 2011 www.cancerPETRegistry.org Sample Physician Office Medicare/Managed Medicare NaF-PET/CT Study - skull vertex to feet Initial Treatment Strategy (Breast Cancer) Non-Hospital Global Managed Medicare Submit claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NaF NOPR claims. 123-45-6789 X Siegel, Bonnie 01 17 1934 123 Any Street AS Siegel, Bonnie 123 Any Street X Any City 00010 X Any City X xxx xxx xxxx xxx xxx xxxx 00010 X Form Locator 21 & 24E: X Enter ICD-9-CM code for principle diagnosis in FL 21. Enter the line number corresponding to the procedure in FL 24E 174.9 Breast (female), unspecified X 01 17 1934 X Medicare Signature On File Form Locator 24G: Enter the number of units based on the CPT or HCPCS code description (NOTE some payers require this field blank for use with Q0 (Zero.) 174.9 02 8 2011 02 8 2011 11 78816 Q0 PI 1 XXXX.XX 1 02 8 2011 02 8 2011 11 A9580 1 XXX.XX 1 Form Locator 24D & 19: Enter CPT or HCPCS code for technical procedures performed by the PET center. 78816 PET/CT Whole Body A9580 NaF Sodium Fluoride, diagnostic, per study dose, up to 30 millicuries NO modifier, Global (Professional & Technical) Q0 (zero) Investigational clinical service provided in a clinical research study that is in an approved clinical research study XXX.XX PI PET or PET/CT to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing FL 19 In order to facilitate coverage and payment list description as NOPR Patient (Note some contractors require this field remain blank, if you experience difficulty try leaving field blank. XXXXXXX CPT codes, descriptions and 2-digit numeric modifiers only are copyright, 2009 AMA. All rights Reserved Educational Materials Prepared for National Oncologic PET Registry Revised: February 2011 www.cancerPETRegistry.org