We reimburse radiopharmaceutical procedure codes in accordance with the instruction in the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 17. We pay diagnostic radiopharmaceuticals at acquisition/invoice cost; and therapeutic radiopharmaceuticals are paid at 95% of the average wholesale price (AWP).
Diagnostic radiopharmaceuticals are paid according to the acquisition/invoice cost reported on the claim. If the total acquisition/invoice cost is not listed or insufficient to determine a rate, the service will be denied. The actual invoice is not required for payment of a diagnostic radiopharmaceutical agent. We will conduct random audits to validate the information provided on the claim. You will receive a request for the actual invoice if your claim is audited.
Radiopharmaceutical procedure codes A4641, A9597, A9598, A9698, A9699, and A9700 are non-specific, or not otherwise classified (NOC) codes. When billing one of these procedure codes on a claim, the provider must report the name of the radiopharmaceutical product represented by the NOC code along with the acquisition/invoice cost in order for the service to be paid. If the necessary information is not reported, the service will be rejected.
Please note that NCD 220.6.17 is only applicable to Fluorodeoxyglucose (FDG) (F-18) Positron Emission Tomography (FDG PET) scans for oncologic conditions. When rendering FDG PET services for oncologic conditions radiopharmaceutical tracer procedure code A9552, Fluorodeoxyglucose F-18, FDG, should be reported.
The FDA label indications should be used to determine reasonable & necessary criteria for ALL non-FDG radiopharmaceuticals and/or radiopharmaceuticals not addressed by a NCD or LCD.
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.
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 that were administered to the patient.
HCPCS code A9512 is defined as Technetium Tc-99m pertechnetate, diagnostic, per mCi.
If the provider administers 5 mCi of this radiopharmaceutical agent for a study, then the number of units would be listed as 5 on the claim.
Note: It is not appropriate to bill per millicurie for HCPCS codes with “per study dose” in the HCPCS code descriptor.
HCPCS code A9595 is defined as Piflufolastat f-18, diagnostic, 1 mCi.
If the provider administers 9 mCi of this radiopharmaceutical agent for a study, then the number of units would be listed as 9 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 for electronic Medicare claim (EMC).
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 approval of a PET oncological indication, 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).
Obtain the amount from the invoice that is applicable for the patient and service on the claim; do not submit the retail amount or amount you charge for the service.
Enter the invoice amount in block 19 of the CMS-1500 paper claim form or its electronic equivalent of Loop 2300 Segment NTE in the following format (including cents):
INV. $00.00
Payment allowance will be made at 100% of the acquisition/invoice cost for diagnostic radiopharmaceuticals and 95% of the AWP for therapeutic radiopharmaceuticals. If the acquisition/invoice cost is not listed appropriately on the claim, or the information is missing from the claim, the service will be denied. If an invoice is attached, this will be reviewed and considered for payment.
Note: Codes listed in this article are not all-inclusive.
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