Reimbursement guidelines for radiopharmaceutical procedure codes (Prior to January 1, 2023)

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Home ► Coverage News ► Reimbursement guidelines for radiopharmaceutical procedure codes (Prior to January 1, 2023)

Last Modified: 2/23/2023 Location: FL, PR, USVI Business: Part B

Reimbursement guidelines for radiopharmaceutical procedure codes (Prior to January 1, 2023)

We recently revised this article to educate on billing certain contractor-priced codes, including radiopharmaceuticals, billed with dates of service prior to January 1, 2023. For instructions regarding how to bill these services with dates of service on or after January 1, 2023, click here.

Background

First Coast reimburses radiopharmaceutical procedure codes in accordance with CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, Drugs and Biologicals. Radiopharmaceuticals are paid at 92% (Florida) and 95% (Puerto Rico/U.S. Virgin Islands) of the most current average wholesale price (AWP).

Radiopharmaceuticals are paid according to the invoice cost for the patient and service when an allowance cannot be calculated. The actual invoice is not required for payment of a radiopharmaceutical agent; however, you must proactively enter the invoice information on your incoming claim. First Coast will reject any claims without the invoice amount or information about the cost associated with the code(s) back to you for correction.

For claims with dates of service prior to January 1, 2023,radiopharmaceutical procedure codes A4641, A9597, A9598, A9698, A9699, and A9700 are Not Otherwise Classified (NOC) codes. When billing one of these procedure codes on a claim, the provider must report the product name, dose, and invoice amount for the service to be paid.

First Coast will conduct random audits to validate the information provided on the claim. If your claim is audited, you will receive an ADR for the actual invoice.

Note: The Food and Drug Administration (FDA) label indications should be used to determine reasonable and necessary criteria for ALL non-FDG radiopharmaceuticals and/or radiopharmaceuticals not addressed by an NCD or LCD.

Coding guidelines

Reminder: Refer to the radiopharmaceutical code descriptors in the relevant HCPCS book.

Most radiopharmaceutical agent code descriptors include “per study dose” and include a range of millicuries. These radiopharmaceutical agents should be billed as one unit of service per study.

Example 1

HCPCS code A9503 is defined as Technetium Tc-99m, medronate, diagnostic, per study dose, up to 30 millicuries.

If the provider administers one to 30 millicuries of this radiopharmaceutical agent for a study, code A9503 should be billed as one unit of service.

Some radiopharmaceutical code descriptors are listed as per millicurie (mCi) or 1 mCi. These agents should be billed per millicurie. The number of services listed in the unit field on the claim should be the number of mCi’s administered to the patient.

Example 2

HCPCS code A9512 is defined as Technetium Tc-99m pertechnetate, diagnostic, per mCi.

If the provider administers five mCi of this radiopharmaceutical agent for a study, then the number of units would be listed as five on the claim.

Note: It is not appropriate to bill per millicurie for HCPCS codes with “per study dose” in the HCPCS code descriptor.

Example 3

HCPCS code A9595 is defined as Piflufolastat f-18, diagnostic, 1 mCi.

If the provider administers nine mCi of this radiopharmaceutical agent for a study, then the number of units would be listed as nine on the claim.

Note: NOC radiopharmaceutical codes (e.g., A4641, A9597, A9598, A9699) should be billed with one unit of service. The claim must include the name, total dosage, and invoice amount of the radiopharmaceutical agent in item 19 of the CMS-1500 form, or the electronic equivalent.

PET Radiopharmaceutical/Tracer codes A9597 or A9598 should be reported only when there is no existing dedicated PET tracer code available. Specifically, there are two circumstances that would warrant the use of A9597 or A9598 as follows:

1. After FDA new product approval, OR

2. After CMS approves coverage of a new PET indication

An appropriate PET CPT code must be reported on the same claim as the PET radiopharmaceutical/tracer code, along with any appropriate modifiers (e.g., PI, PS, or Q0 as applicable).

How to report invoice amount

You must proactively enter the invoice information on your incoming claim.

• Obtain the total invoice cost for the patient and service. You must report the amount from the invoice that is applicable for the patient and service on the claim; you are not reporting the retail amount or amount you charge for the service.

• Enter the invoice amount on block 19 of the CMS-1500 paper claim form or its electronic equivalent of Loop 2400 Segment NTE02 in the following format (including cents):

• INV. $00.00

Claim example

First Coast will reject any claims without the invoice amount or information about the cost associated with the code(s) back to you for correction. The evaluation of codes for this list is an ongoing process. Be sure to check back frequently and subscribe to our eNews.

For more detailed information related to billing NOC codes, please review our Appropriate use of NOC codes when billing for drugs and biologicals article.

Note: Codes listed in this article are not all-inclusive and the guidelines outlined in this article apply to all radiopharmaceutical codes.

References

• CMS IOM Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.6 Positron Emission Tomography (PET) Scans external pdf file

• CMS IOM Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.6.17 Positron Emission Tomography (RET) (FDG) for Oncologic Conditions external pdf file

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, Section 50 Nuclear Medicine external pdf file

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, Section 60.19 Local Coverage Determination for PET Using New, Proprietary Radiopharmaceuticals for their FDA-Approved Labeled Indications for Oncologic Imaging Only external pdf file

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, Section 60.3.2 Tracer Codes Required for Positron Emission Tomography (PET) Scans external pdf file

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, Section 110.3 Payment for Radiopharmaceuticals external pdf file

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 17 external pdf file

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