The Medicare Modernization Act (MMA), Section 303(h), states that for dates of service on or after January 1, 2005, radiopharmaceutical payment allowance limits are not subject to Average Sale Price (ASP). The prices First Coast Service Options Inc. (FCSO) will use, effective for claims with dates of service on or after January 1, 2009, are available in FCSO’s fee schedule lookup tool. Select the FCSO 2009 Part B physician fee schedule for your location, then select “2009 Radiopharmaceutical codes” from the drop-down menu. Note that whenever possible, FCSO uses 92% (for Florida) and 95% (for Puerto Rico and the U.S. Virgin Islands) of the lowest Average Wholesale Price (AWP) for the most current year’s Red Book®.

Valid invoices are required to establish pricing for products that are not described and priced in Red Book. This includes radiopharmaceuticals purchased from a compounding nuclear pharmacy that have been altered/compounded (i.e., divided and repackaged or not prepared according to the labeled instructions). A valid invoice must be patient-specific, containing the patient’s name in printed form. Patients’ names hand-written on the invoice are not acceptable. In instances where this is not possible, the invoice will be considered valid if accompanied by a patient’s specific medical note or written order for the radiopharmaceutical. (Note: Electronic claim submissions will be developed to request this information.) The invoice date should be within 30 days of, but no more than 45 days after, the date of service.

As a reminder, some HCPCS code descriptions have changed from “dose” to “study dose.” Appropriate billed amounts should reflect the cost of the “study dose” on the claim. When billing radiopharmaceuticals, the dollar amount the physician pays for the product (per invoice) should be the total billed amount submitted on the claim. The billed amount on the claims should reflect the physician’s cost not the reimbursement amount. (Physician’s cost includes off-invoice discounts/rebates). For example: A9605- (Quadramet) Samarium Sm-153 lexidronamm, therapeutic, per 50 millicuries; based on the 2008 Red Book page 693 Quadramet is packaged as a 50mCi/ml, 3ml single dose vial. FCSO allowed $4918.59 for Florida and $5078.98 for Puerto Rico/U.S. Virgin Islands; this allowance was based on three units or 150 mCi. If a provider administers 50 mCi, his or her claim to Medicare should represent one unit, and the bill amount should reflect the actual cost of 50 mCi. When a provider administers 150mCi, his or her claim should represent three units and the bill amount should reflect the actual cost of the 150 mCi. Providers who may have inadvertently billed either the incorrect number of units or did not adjust their billed amount to cost are encouraged to perform an internal audit, correct any errors, and submit voluntary refunds to Medicare within 45 days of this notice. This applies to any radiopharmaceutical that may have been incorrectly billed to the Medicare program.

Purchase invoices, discounts, and rebates must be maintained in the patients’ medical record, and the invoice and/or medical record must contain all of the following information: