Notification



Notification Issue Date:



Claim Payment Policy


Title:Reimbursement for Diagnostic and Therapeutic Radiopharmaceutical Agents for Professional Providers

Policy #:09.00.32t

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage contract.

RADIOPHARMACEUTICAL AGENTS WITH PET SCANS

Reimbursement for medically necessary radiopharmaceutical agents used in conjunction with PET scans is included in the reimbursement for the associated procedure. Therefore, the radiopharmaceutical agents are not eligible for separate reimbursement.

RADIOPHARMACEUTICAL AGENTS --- OTHER USES

Reimbursement for medically necessary radiopharmaceutical agents other than those used in conjunction with PET scans are eligible for reimbursement as follows:
  • Medically necessary radiopharmaceutical agents purchased by a professional provider and administered in an office setting are eligible for reimbursement.
  • Medically necessary radiopharmaceutical agents administered in a facility setting are not eligible for reimbursement to a professional provider as payment is included in the facility reimbursement.
  • Medically necessary radiopharmaceutical agents administrated by facilities are reimbursed in accordance with the facility contract or agreement.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Report radiopharmaceutical agents as follows:
  • Radiopharmaceutical agents that include "per study dose" in the HCPCS description should be reported once per study performed. If more than one study is performed, the appropriate codes or units should be reported for each study.
    Example 1:
    When administering Tc99m-Tetrofosmin, diagnostic, per study dose (HCPCS A9502) to perform myocardial perfusion imaging, single study at rest or stress (CPT 78451), the provider should report one (1) unit only.
    Example 2:
    When administering Tc99m-Tetrofosmin, diagnostic, per study dose (HCPCS A9502) to perform myocardial perfusion imaging, multiple studies at rest and/or stress (CPT 78452), the provider may report two (2) units when two separate doses are administered (e.g., one dose at rest and another dose during stress).
  • Radiopharmaceutical agents that include "per microcurie" or "per millicurie" in the HCPCS description should be reported with the actual dose administered during the study (in microcuries or millicuries). This amount is not to exceed the maximum amount allowed based on the code description and must represent only the amount actually administered.
    Example:
    When administering I-131 sodium iodide, diagnostic, per microcurie (up to 100 mci) (HCPCS A9531) to perform thyroid uptake, multiple determinations (CPT 78001), if the provider orders 50 microcuries but administers only 10 microcuries of this agent to perform this study, 10 units should be reported.
  • Radiopharmaceutical agents that include "per treatment" in the HCPCS description should be reported once per treatment performed.
    Example:
    When administering Y-90 ibritumomab tiuxitan, therapeutic, per treatment dose, up to 40 millicurie (HCPCS A9543) to perform radiopharmaceutical therapy, by intravenous administration (CPT 79101), if the provider administered 29 millicuries of this agent to perform this therapy, only one (1) unit should be reported.
  • Radiopharmaceutical agents that include " per microcurie" or "per millicurie" in the HCPCS description should be reported with the actual treatment dose administered (in microcuries or millicuries). This amount is not to exceed the maximum amount allowed based on the code description and must represent only the amount actually administered.
    Example:
    When administering I-131 sodium iodide solution, therapeutic, per millicurie (HCPCS A9530) to perform radiopharmaceutical therapy, by oral administration (CPT 79005), if the provider orders 16 millicuries but administers only 10 millicuries of this agent to perform this therapy, only 10 units should be reported.

"Not otherwise classified" radiopharmaceutical agents A4641 and A9699 should only be reported in the exceptional circumstance when a more specific code does not exist for the radiopharmaceutical agent. When reporting A4641 or A9699, the provider should report only one unit and include a description of the agent and the actual amount administered.
  • If no specific HCPCS code exists for the diagnostic agent, the provider should use HCPCS code A4641 and include a description of the diagnostic radiopharmaceutical agent along with the actual dose amount administered.
  • If no specific HCPCS code exists for the therapeutic agent, the provider should use HCPCS code A9699 and include a description of the therapeutic radiopharmaceutical agent along with the actual dose amount administered.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, radiopharmaceutical agents are covered under the medical benefits of the Company's products.

In geographical areas with a capitated outpatient radiology program, radiopharmaceutical agents are not included in the capitated radiology program and may be eligible for fee-for-service reimbursement when all of the policy requirements are met.

Description

Radiopharmaceutical agents are radioactive chemicals or drugs that have a specific affinity for a particular body tissue or organ. They can be used in conjunction with diagnostic procedures to obtain images of structures. They can also be used in conjunction with therapeutic procedures to treat radiation sensitive diseases.
References


Centers for Medicare and Medicaid Services (CMS). Billing and Coding Guidelines for Radiopharmaceutical Agents (RAD-026). 90.2 Drugs, Biologicals, and Radiopharmaceuticals. Coding Radiopharmaceuticals.[CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/lcd_attachments/31361_1/L31361_RAD026_CBG_060111.pdf. Accessed March 8, 2018.

Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 17: Drugs and Biologicals. 90.2: Drugs, Biologicals, and Radiopharmaceuticals. [CMS Web site]. Available at: https://www.cms.gov/manuals/downloads/clm104c17.pdf. Accessed March 8, 2018.

Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 13: Radiology services and other diagnostic procedures. 110.3: Payment for radiopharmaceuticals. [CMS Web site]. Available at: https://www.cms.gov/manuals/downloads/clm104c13.pdf. Accessed March 8, 2018.

Company Benefit Contracts.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



DIAGNOSTIC RADIOPHARMACEUTICALS USED FOR NUCLEAR IMAGING PROCEDURES OTHER THAN POSITRON EMISSION TOMOGRAPHY (PET) SCANS

A4642: Indium In-111 satumomab pendetide, diagnostic, per study dose, up to 6 millicuries
A9500: Technetium Tc-99m sestamibi, diagnostic, per study dose
A9501: Technetium tc-99m teboroxime, diagnostic, per study dose
A9502: Technetium Tc-99m tetrofosmin, diagnostic, per study dose,
A9503: Technetium Tc-99m, medronate, diagnostic, per study dose, up to 30 millicuries
A9504: Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 millicuries
A9505: Thallium Tl-201 thallous chloride, diagnostic, per millicurie
A9507: Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries
A9508: Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie
A9509: Iodine I-123 sodium iodide, diagnostic, per millicurie
A9510: Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries
A9512: Technetium Tc-99m pertechnetate, diagnostic, per millicurie
A9516: iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries
A9520: Technetium Tc-99m, tilmanocept, diagnostic, up to 0.5 millicuries
A9521: Technetium Tc-99m exametazine, diagnostic, per study dose, up to 25 millicuries
A9524: Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries
A9528: Iodine I-131 sodium iodide capsule(s), diagnostic, per millicurie
A9529: Iodine I-131 sodium iodide solution, diagnostic, per millicurie
A9531: Iodine I-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries)
A9532: Iodine I-125, serum albumin, diagnostic, per 5 microcuries
A9536: Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries
A9537: Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries
A9538: Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries
A9539: Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries
A9540: Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries
A9541: Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries
A9542: Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries
A9546: Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie
A9547: Indium In-111 oxyquinoline, diagnostic, per 0.5 millicurie
A9548: Indium In-111 pentetate, diagnostic, per 0.5 millicurie
A9550: Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicuries
A9551: Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 millicuries
A9553: Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries
A9554: Iodine I-125 sodium iothalamate, diagnostic, per study dose, up to 10 microcuries
A9556: Gallium Ga-67 citrate, diagnostic, per millicurie
A9557: Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 millicuries
A9558: Xenon Xe-133 gas, diagnostic, per 10 millicuries
A9559: Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie
A9560: Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries
A9561: Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 millicuries
A9562: Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries
A9566: Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 millicuries
A9567: Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries
A9568: Technetium Tc-99m arcitumomab diagnostic , per study dose, up to 45 millicuries
A9569: Technetium tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose
A9570: Indium in-111 labeled autologous white blood cells, diagnostic, per study dose
A9571: Indium in-111 labeled autologous platelets, diagnostic, per study dose
A9572: Indium in-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries
A9582: Iodine I-123 Iobenguane, diagnostic, per study dose, up to 15 millicuries
Q9969: Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose

THE FOLLOWING GENERAL CODE SHOULD BE USED TO REPORT THE SUPPLY OF DIAGNOSTIC RADIOPHARMACEUTICAL AGENTS WHEN NOT LISTED ABOVE

A4641: Radiopharmaceutical, diagnostic, not otherwise classified


DIAGNOSTIC RADIOPHARMACEUTICALS USED WITH PET

The following diagnostic radiopharmaceuticals should only be reported when used with positron emission tomography (PET). These radiopharmaceuticals are not eligible for separate reimbursement.
A9515: Choline c-11, diagnostic, per study dose up to 20 millicuries
A9526: Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries
A9552: Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
A9555: Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries
A9580: Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries
A9586: Florbetapir f18, diagnostic, per study dose, up to 10 millicuries
A9587: Gallium ga-68, dotatate, diagnostic, 0.1 millicurie
A9588: Fluciclovine f-18, diagnostic, 1 millicurie
A9597: Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified
A9598: Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified
Q9982: Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries
Q9983: Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries

THERAPEUTIC RADIOPHARMACEUTICALS

A9517: Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie
A9527: Iodine I-125 sodium iodide solution, therapeutic, per millicurie
A9530: Iodine I-131 sodium iodide solution, therapeutic, per millicurie
A9543: Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries
A9563: Sodium phosphate P-32, therapeutic, per millicurie
A9564: Chromic phosphate P-32 suspension, therapeutic, per millicurie
A9600: Strontium Sr-89 chloride, therapeutic, per millicurie
A9604: Samarium SM-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries
A9606: Radium ra-223 dichloride, therapeutic, per microcurie


THE FOLLOWING GENERAL CODE SHOULD BE USED TO REPORT THE SUPPLY OF THERAPEUTIC RADIOPHARMACEUTICAL AGENTS WHEN NOT LISTED ABOVE

A9699: Radiopharmaceutical, therapeutic, not otherwise classified


Revenue Code Number(s)



0343: Diagnostic Radiopharmaceuticals

0344: Therapeutic Radiopharmaceuticals

Coding and Billing Requirements


Cross References


Policy History

REVISIONS FROM 09.00.32t
09/24/2018This policy will be effective 09/24/2018. This policy has undergone a routine review, the coverage position remains unchanged. Policy language was revised to clarify the Professional Provider and Facility reimbursement.


REVISIONS FROM 09.00.32s
01/01/2018This policy has been identified for the CPT code update.

The following CPT code has been deleted from this policy, effective 12/31/2017: A9599


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 09/24/2018
Version Issued Date: 09/24/2018
Version Reissued Date: N/A

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