R13968OTN: International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)- October 2026

REQUIREMENTS: 1. IMMEDIATELY (Before October 1, 2026): - Billing team must verify current system edits for NCD 220.6.1 (PET Perfusion of the Heart) and NCD 150.3 (Bone Mineral Density Studies) - Contact your Medicare Administrative Contractor (MAC) to confirm implementation timeline 2. By January 1, 2024 (RETROACTIVE - may already be in effect): - Billing team must ensure CPT codes 0554T, 0555T, 0556T, 0557T, and 0558T are marked as PAYABLE (not monitoring) in billing system for bone density studies - System must waive co-insurance and deductible for these codes - Update frequency edits to include these new CPT codes for diagnostic indications only - Add these codes to MBD/NGD extract and provider query screens 3. By April 1, 2025: - Billing system must make existing edits for NCD 220.6.1 (PET cardiac imaging) OVERRIDABLE - System administrators must create parameter screens (PARM) for tracer codes that can be updated by MACs - Load parameter screens with historical tracer information from Reason Codes 32438 and 32440 with effective/term dates - Add HCPCS codes A9598 (effective 1/1/2018) and A9611 (effective 4/1/2025) to the parameter screens - Add CPT codes 78430-78434 into edit logic for Reason Code 32438 4. ONGOING: - When denying claims related to these NCDs, use CAQH CORE standard messaging: RARC N386 with CARC 50, 96, or 119 - For claims denied without signed ABN: Use Group Code CO (Contractual Obligation) with CARC 50 and MSN 8.81 - For claims with signed ABN (modifier GA or occurrence code 32): Use Group Code PR (Patient Responsibility) CONSEQUENCES: Failure to implement edits and code updates will result in incorrect claim processing, potential denials, and compliance violations. Claims for PET cardiac imaging and bone density studies may be incorrectly denied or processed without proper frequency controls.