Axumin® PET Scans: A Breakthrough for Prostate Cancer

By Mindy Michno, CPC, RCC, Corporate Coding Manager - Radiology

Effective October 1, 2017, Transmittal 1875 (CR 10086) updated Medicare’s National Coverage Determination for PET (NCD 220.6) to specify coverage for HCPCS A9588 (Axumin®). A9588 (Axumin®) has only been approved for suspected prostate cancer recurrence and is therefore restricted to ICD-10 diagnosis codes, including:

  • C61 – Malignant neoplasm of prostate
  • Z85.46 – Personal history of malignant neoplasm of prostate

Modifier PS is required as PET for initial treatment strategy of prostate cancer remains nationally non-covered. MACs without a specific LCD addressing Axumin® must also default to the NCD coverage policy and instructions for Axumin® studies. As well, Noridian, Novitas, and WPS have local coverage articles indicating the coverage of A9588 when reported in conjunction with PET codes 78811-78816, and a prostate cancer (C61)/history of prostate cancer (Z85.46) diagnosis.

Below are documentation guidelines that radiologists should follow for these PET scans:

  • PET scans for diagnosing or initial treatment strategy for prostate cancer remain Nationally Non-Covered
  • Please indicate Subsequent scan either in the technique or clinical indication portion of the documentation

Although this will most likely be the patient’s first PET related to prostate cancer, it is considered a subsequent (re-staging, post treatment) PET as the patient will have already had some kind of treatment, etc., since their initial diagnosis of prostate cancer.

Indications with specific reference to Initial scan will be brought to physicians’ attention for addendums.

Clinical Indication must include reference to prostate cancer, as shown below.

  • There should be a subsequent scan for current prostate cancer.
  • There should be a subsequent scan following completed treatment for prostate cancer.
  • There should be a history of prostate cancer, with a subsequent scan due to rising PSA levels.
  • Ask whether there is a possible prostate cancer recurrence, with a subsequent scan.

Axumin® is reported per 1 millicurie (mCi) used

  • Per the manufacturer, Axumin® is packaged in 10 mCi single use vials
  • Even though the radioactivity level actually given to the patient varies, the 10 mCi dose provided by the vendor on the invoice will be reported on the claim.

Finally, it’s important to note the patient-specific invoice is required for all Axumin®studies.

Resources:

CMS NCD Manual (220.6)
CMS Transmittal 1875 (CR 10086); July 27, 2017
CMS Transmittal 1854; May 26, 2017
SNMMI Coding Corner Q&A
MAC LCD – Noridian, WPS, Novitas
PETNET