1. PET/CT base of skull to mid-thigh study Subsequent Treatment Strategy 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 2010 www.cancerPETRegistry.org Siegel, Bonnie 12/28/2009 123 Any Street Any City Any State USA Any Hospital One Hospital Road Any City, Any State 00010 222222 01/17/1934 F 0404 0343 NOPR PET/CT Torso 12/28/2009 1XXXX.XX XXX.XX 12/28/2009 1F-18 FDG per dose 78815 Q0 PS A9552 Bonnie Siegel 1889 Form Locator 67 & 68: Enter ICD-9-CM code for principle diagnosis in FL 67. 188.9 Malignant neoplasm of bladder, part unspecified Enter NOPR Identifier in FL 68 V70.7 Exam of Participants in Clinical Trials 1122431 123-45-6789 XXXXXXXXX Medicare XXXXXXXXX Form Locator 42: Enter revenue codes. 0404 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. 78815 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 PS PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy V707 131 66-66678 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. 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. 3030

2. XXX.XX Sample Physician Billing Medicare/Managed Medicare Hospital Outpatient Setting 188.9 Siegel, Bonnie 123 Any Street Any City AS 00010 xxx xxx xxxx X X X X X X X 123-45-6789 X01 17 1934 Siegel, Bonnie 123 Any Street Any City 00010 xxx xxx xxxx 12 28 2009 1 1 78815 26 Q0 PS 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 Subsequent Treatment Strategy 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 78815 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 PS PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy 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 188.9 Malignant neoplasm of bladder, part unspecified Educational Materials Prepared for National Oncologic PET Registry Revised: September 2010 www.cancerPETRegistry.org 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.

3. XXX.XX Sample Physician Office Medicare/Managed Medicare Non-Hospital Technical 188.9 Siegel, Bonnie 123 Any Street Any City AS 00010 xxx xxx xxxx X X X X X X X 123-45-6789 X01 17 1934 Siegel, Bonnie 123 Any Street Any City 00010 xxx xxx xxxx 12 28 2009 1 1 78815 TC Q0 PS 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 Subsequent Treatment Strategy 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. 78815 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 PS PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy 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 188.9 Malignant neoplasm of bladder, part unspecified 12 28 2009 11 A9552 1 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 2010 www.cancerPETRegistry.org 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.

4. XXX.XX Sample Physician Office Medicare/Managed Medicare Non-Hospital Global 188.9 Siegel, Bonnie 123 Any Street Any City AS 00010 xxx xxx xxxx X X X X X X X 123-45-6789 X01 17 1934 Siegel, Bonnie 123 Any Street Any City 00010 xxx xxx xxxx 12 28 2009 1 1 78815 Q0 PS 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 Subsequent Treatment Strategy 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. 78815 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 PS PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy 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 188.9 Malignant neoplasm of bladder, part unspecified 12 28 2008 12 28 2009 11 A9552 1 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 2010 www.cancerPETRegistry.org 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.