1. NaF PET/CT skull vertex to feet Subsequent Treatment Strategy Prostate Cancer 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: February 2011 www.cancerPETRegistry.org Siegel, Bob 02/8/2011 123 Any Street Any City Any State USA Any Hospital One Hospital Road Any City, Any State 00010 222222 01/17/1934 M 0404 0343 NaF NOPR PET/CT Whole Body 02/8/2011 1XXXX.XX XXX.XX 02/8/2011 1NaF, per study dose 78816 Q0 PS A9580 Bob Siegel 185 Form Locator 67 & 68: Enter ICD-9-CM code for principle diagnosis in FL 67. 185 Malignant neoplasm of prostate 198.5 Bone and bone marrow V67.2 Following chemotherapy Cancer chemotherapy follow-up Enter NOPR Identifier in FL 68 in second diagnosis position 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. 78816 PET/CT Whole Body A9580 NaF, sodium fluoride, 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 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 131 66-66678 Managed Medicare Submit claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NaF NOPR claims. 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. 30 V707 1985V672

2. XXX.XX Sample Physician Billing Medicare/Managed Medicare Hospital Outpatient Setting Siegel, Bob 123 Any Street Any City AS 00010 xxx xxx xxxx X X X X X X X 123-45-6789 X01 17 1934 Siegel, Bob 123 Any Street Any City 00010 xxx xxx xxxx 02 8 2011 1 1 78816 26 Q0 PS KX 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.) 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 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 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 KX Requirements specified in the medical policy have been met 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 185 Malignant neoplasm of prostate 198.5 Bone and bone marrow V67.2 Following chemotherapy Cancer chemotherapy follow-up Educational Materials Prepared for National Oncologic PET Registry Revised: February 2011 www.cancerPETRegistry.org Managed Medicare Submit claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NaF NOPR claims. 185. V67 2. 198.5 NaF PET/CT skull vertex to feet Subsequent Treatment Strategy Prostate Cancer

3. XXX.XX Sample Physician Office Medicare/Managed Medicare Non-Hospital Technical Siegel, Bob 123 Any Street Any City AS 00010 xxx xxx xxxx X X X X X X X 123-45-6789 X01 17 1934 Siegel, Bob 123 Any Street Any City 00010 xxx xxx xxxx 02 8 2011 1 1 78816 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 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. 78816 PET/CT Whole Body A9580 NaF, sodium fluoride, diagnostic, per study dose, per 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 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 185 Malignant neoplasm of prostate 198.5 Bone and bone marrow V67.2 Following chemotherapy Cancer chemotherapy follow-up 02 8 2011 11 A9580 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 February 2011 www.cancerPETRegistry.org 185. V67 2. 198.5 Managed Medicare Submit claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NaF NOPR claims. NaF PET/CT skull vertex to feet Subsequent Treatment Strategy Prostate Cancer

4. XXX.XX Sample Physician Office Medicare/Managed Medicare Non-Hospital Global 185. Siegel, Bob 123 Any Street Any City AS 00010 xxx xxx xxxx X X X X X X X 123-45-6789 X01 17 1934 Siegel, Bob 123 Any Street Any City 00010 xxx xxx xxxx 02 8 2011 1 1 78816 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 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. 78816 PET/CT Whole Body A9552 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 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 185 Malignant neoplasm of prostate 198.5 Bone and bone marrow V67.2 Following chemotherapy Cancer chemotherapy follow-up 02 8 2011 11 A9580 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: February 2011 www.cancerPETRegistry.org V67 2. 198.5 Managed Medicare Submit claim to Medicare Administrative Contractor (MAC) for payment instead of Managed Medicare Contractor for all NaF NOPR claims. NaF PET/CT skull vertex to feet Subsequent Treatment Strategy Prostate Cancer