PET/CT base of skull to mid-thigh study Initial Treatment Strategy (Leukemia) Sample Hospital Billing Medicare / Managed Medicare Hospital Outpatient Setting 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: September Siegel, Bonnie 12/28/ Any Street Any City Any State USA Any Hospital One Hospital Road Any City, Any State /17/1934 F NOPR PET/CT Torso 12/28/2009 1XXXX.XX XXX.XX 12/28/2009 1F-18 FDG per dose Q0 PI A9552 Bonnie Siegel Form Locator 67 & 68: Enter ICD-9-CM code for principle diagnosis in FL Lymphoid leukemia, chronic, without mention of having achieved remission, failed remission Enter NOPR Identifier in FL 68 V70.7 Exam of Participants in Clinical Trials XXXXXXXXX Medicare XXXXXXXXX Form Locator 42: Enter revenue codes PET Procedures 0343 Diagnostic Radiopharmaceutical Form Locator 46: Enter the number of units based on the CPT or HCPCS code description Form Locator 44: Enter CPT or HCPCS code for procedures and radiopharmaceuticals or drug PET/CT Skull base to mid-thigh A9552 F-18 FDG, diagnostic, per study dose, up to 45 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 V 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/ Form Locator 24-30: Enter the condition “30” Qualifying Clinical Trials Non-research services provided to all patients, including managed care enrollees enrolled in a Qualified Clinical Trial.

XXX.XX Sample Physician Billing Medicare/Managed Medicare Hospital Outpatient Setting Siegel, Bonnie 123 Any Street Any City AS xxx xxx xxxx X X X X X X X X Siegel, Bonnie 123 Any Street Any City xxx xxx xxxx Q0 PI XXXX.XX 22 Medicare Signature On File XXXXXXX 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.) PET/CT base of skull to mid-thigh study Initial Treatment Strategy (Leukemia) CPT codes, descriptions and 2-digit numeric modifiers only are copyright, 2009 AMA. All rights Reserved Form Locator 24D & 19: Enter CPT or HCPCS code for procedures interpreted by the physician In the hospital outpatient setting PET/CT skull base to mid-thigh 26 modifier, Professional Component 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 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. Form Locator 21 & 24E: Enter ICD-9-CM code for principle diagnosis in FL 21. Enter the line number corresponding to the procedure in FL 24E Lymphoid leukemia, chronic, without mention of having achieved remission, failed remission Educational Materials Prepared for National Oncologic PET Registry Revised: September 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.

XXX.XX Sample Physician Office Medicare/Managed Medicare Non-Hospital Technical Siegel, Bonnie 123 Any Street Any City AS xxx xxx xxxx X X X X X X X X Siegel, Bonnie 123 Any Street Any City xxx xxx xxxx TC Q0 PI XXXX.XX 11 Medicare Signature On File XXXXXXX Form Locator 24G: Enter the number of units based on the CPT or HCPCS code description PET/CT base of skull to mid-thigh study Initial Treatment Strategy (Leukemia) CPT codes, descriptions and 2-digit numeric modifiers only are copyright, 2009 AMA. All rights Reserved Form Locator 24D & 19: Enter CPT or HCPCS code for technical procedures performed by the PET center PET/CT skull base to mid-thigh A9552 F-18 FDG per dose TC modifier, Technical Component 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 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. Form Locator 21 & 24E: Enter ICD-9-CM code for principle diagnosis in FL 21. Enter the line number corresponding to the procedure in FL 24E Lymphoid leukemia, chronic, without mention of having achieved remission, failed remission A XXX.XX 1 (NOTE some payers require this field blank for use with Q0 (Zero.) Educational Materials Prepared for National Oncologic PET Registry Revised: September 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.

XXX.XX Sample Physician Office Medicare/Managed Medicare Non-Hospital Global Siegel, Bonnie 123 Any Street Any City AS xxx xxx xxxx X X X X X X X X Siegel, Bonnie 123 Any Street Any City xxx xxx xxxx Q0 PI XXXX.XX 11 Medicare Signature On File XXXXXXX Form Locator 24G: Enter the number of units based on the CPT or HCPCS code description PET/CT base of skull to mid-thigh study Initial Treatment Strategy (Leukemia) CPT codes, descriptions and 2-digit numeric modifiers only are copyright, 2009 AMA. All rights Reserved Form Locator 24D & 19: Enter CPT or HCPCS code for technical procedures performed by the PET center PET/CT skull base to mid-thigh A9552 F-18 FDG per dose NO modifier, Global (Professional & Technical) 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 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. Form Locator 21 & 24E: Enter ICD-9-CM code for principle diagnosis in FL 21. Enter the line number corresponding to the procedure in FL 24E Lymphoid leukemia, chronic, without mention of having achieved remission, failed remission A XXX.XX 1 (NOTE some payers require this field blank for use with Q0 (Zero.) Educational Materials Prepared for National Oncologic PET Registry Revised: September 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.