Coding For Nuclear Medicine

Radiopharmaceuticals

Int roduct ion

The process of assigning HCPCScodes and units for radioisotopes and imaging-related drugs for nuclear medicine services can be quite challenging. This is because there are often multiple codes available for the same substance depending on factors such as dosage and whether the drug is being used for therapeutic or diagnostic purposes Additionally, different payers may have different requirements, such as requesting a copy of the invoice or National Drug Code (NDC) for the substance. Furthermore, the codes and guidelines for imaging agents tend to change more frequently than those for imaging services.

Coding and Billing for Radiopharm aceut icals

Alphanumeric Level II HCPCScodes are utilized to invoice Medicare and other payers for pharmaceuticals and drugs Radiopharmaceuticals are measured in curies, which is a unit of radioactivity.

Some HCPCScodes for radiopharmaceuticals are defined in terms of millicuries (mCi), while others are defined in terms of microcuries (uCi) The kits used for the administration of radiopharmaceuticals, such as the Insta/Vent? system for lung scans, are included in the reimbursement for the study and are not reported separately.

While most radiopharmaceuticals are bundled into the charge for the radiology service, some expensive radiopharmaceuticals do carry separate reimbursement under Medicare?s hospital outpatient reimbursement methodology (OPPS). Drugs listed as status K or status G under OPPSare separately payable. For example, A9543 (Y-90/Zevalin) carries a substantial amount of additional reimbursement:

Nuclearmedicineradiopharmaceuticals

Other HCPCSfor radiopharmaceuticals such as Pylarify® , QuadraMet® , Illucix® , Pluvicto? , Metastron, and Locametz® all also carry a significant amount of separate reimbursement when reported in addition to the radiology procedure code

Nuclearmedicineradiopharmaceuticals

In most cases, submitting charges for contrast and radiopharmaceuticals will not result in additional Medicare reimbursement for an OPPSfacility or Critical Access Hospital.

However, it is still important to report the charge for the radiopharmaceutical for two reasons:

- Medicare bases APCreimbursement on cost data collected from hospital claims, and

- Some payers (like Medicaid) will reimburse contrast separately

Non-Highly Enriched Uranium Sources

Hospitals providing technetium Tc-99m labeled isotopes for nuclear medicine imaging services may be eligible for additional reimbursement if the isotope used in the procedure was obtained from a non-Highly Enriched Uranium (HEU) source. In order to encourage facilities to use non-HEU source isotopes, Medicare will pay an additional $10 per study dose if the add-on HCPCSQ9969 is reported in addition to the A95XXcode: