MA PPO

Reimbursement for Radiopharmaceutical Agents for Professional Providers
MA09.009j


Policy


Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology
may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, radiopharmaceutical agents
are covered under the medical benefits of the Company’s Medicare Advantage 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. September 12, 2019.

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]. 02/08/19. Available at: https://www.cms.gov/manuals/downloads/clm104c17.pdf. Accessed September 12, 2019.

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]. 03/27/19. Available at: https://www.cms.gov/manuals/downloads/clm104c13.pdf. Accessed September 12, 2019.

Novitas Solutions, Inc. Reimbursement Guidelines for Diagnostic Radiopharmaceutical Procedure Codes. 08/27/19. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00024985. Accessed October 15, 2019.

Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)


ICD - 10 Diagnosis Code Number(s)


HCPCS Level II Code Number(s)
RADIOPHARMACEUTICAL AGENTS USED WITH PET POSITRON EMISSION TOMOGRAPHY (PET) SCANS
The following radiopharmaceuticals should only be reported when used with PET scans. They are not eligible for separate reimbursement.

A9515Choline C-11, diagnostic, per study dose up to 20 mCi
A9526Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 mCi
A9552Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi
A9555Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi
A9580Sodium fluoride F-18, diagnostic, per study dose, up to 30 mCi
A9586Florbetapir F18, diagnostic, per study dose, up to 10 mCi
A9587Gallium Ga-68, dotatate, diagnostic, 0.1 mCi
A9588Fluciclovine F-18, diagnostic, 1 mCi
A9597Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified
A9598Positron emission tomography radiopharmaceutical, diagnostic, for nontumor identification, not otherwise classified
Q9982Flutemetamol F18, diagnostic, per study dose, up to 5 mCi
Q9983Florbetaben F18, diagnostic, per study dose, up to 8.1 mCi

RADIOPHARMACEUTICAL AGENTS USED WITH PROCEDURES OTHER THAN POSITRON EMISSION TOMOGRAPHY (PET) SCANS

A4642Indium In-111 satumomab pendetide, diagnostic, per study dose, up to 6 mCi
A9500Technetium Tc-99m sestamibi, diagnostic, per study dose
A9501Technetium Tc-99m teboroxime, diagnostic, per study dose
A9502Technetium Tc-99m tetrofosmin, diagnostic, per study dose
A9503Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 mCi
A9504Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 mCi
A9505Thallium Tl-201 thallous chloride, diagnostic, per mCi
A9507Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries
A9508Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 mCi
A9509Iodine I-123 sodium iodide, diagnostic, per mCi
A9510Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 mCi
A9512Technetium Tc-99m pertechnetate, diagnostic, per mCi
A9516Iodine I-123 sodium iodide, diagnostic, per 100 mcCi, up to 999 mcCi
A9517Iodine I-131 sodium iodide capsule(s), therapeutic, per mCi
A9520Technetium Tc-99m, tilmanocept, diagnostic, up to 0.5 mCi
A9521Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 mCi
A9524Iodine I-131 iodinated serum albumin, diagnostic, per 5 mcCi
A9527Iodine I-125, sodium iodide solution, therapeutic, per mCi
A9528Iodine I-131 sodium iodide capsule(s), diagnostic, per mCi
A9529Iodine I-131 sodium iodide solution, diagnostic, per mCi
A9530Iodine I-131 sodium iodide solution, therapeutic, per mCi
A9531Iodine I-131 sodium iodide, diagnostic, per mcCi (up to 100 mcCi)
A9532Iodine I-125 serum albumin, diagnostic, per 5 mcCi
A9536Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 mCi
A9537Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 mCi
A9538Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 mCi
A9539Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 mCi
A9540Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 mCi
A9541Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 mCi
A9542Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 mCi
A9543Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 mCi
A9546Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 mcCi
A9547Indium In-111 oxyquinoline, diagnostic, per 0.5 mCi
A9548Indium In-111 pentetate, diagnostic, per 0.5 mCi
A9550Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 mCi
A9551Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 mCi
A9553Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 mcCi
A9554Iodine I-125 sodium iothalamate, diagnostic, per study dose, up to 10 mcCi
A9555Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi
A9556Gallium Ga-67 citrate, diagnostic, per mCi
A9557Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 mCi
A9558Xenon Xe-133 gas, diagnostic, per 10 mCi
A9559Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 mcCi
A9560Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 mCi
A9561Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 mCi
A9562Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 mCi
A9563Sodium phosphate P-32, therapeutic, per mCi
A9564Chromic phosphate P-32 suspension, therapeutic, per mCi
A9566Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 mCi
A9567Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 mCi
A9568Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 mCi
A9569Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose
A9570Indium In-111 labeled autologous white blood cells, diagnostic, per study dose
A9571Indium In-111 labeled autologous platelets, diagnostic, per study dose
A9572Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 mCi
A9582Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 mCi
A9584Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 mCi
A9600Strontium Sr-89 chloride, therapeutic, per mCi
A9604Samarium Sm-153 lexidronam, therapeutic, per treatment dose, up to 150 mCi
A9606Radium RA-223 dichloride, therapeutic, per mcCi
Q9969Tc-99m from nonhighly enriched uranium source, full cost recovery add-on, per study dose

THE FOLLOWING NOT OTHERWISE CLASSIFIED (NOC) CODES SHOULD BE USED TO REPORT THE SUPPLY OF RADIOPHARMACEUTICAL AGENTS WHEN NOT LISTED ABOVE

A4641Radiopharmaceutical, diagnostic, not otherwise classified
A9699Radiopharmaceutical, therapeutic, not otherwise classified

Revenue Code Number(s)
0343 Diagnostic Radiopharmaceuticals
0344 Therapeutic Radiopharmaceuticals


Coding and Billing Requirements



Policy History

12/2/2019
12/2/2019
MA09.009
Claim Payment Policy Bulletin
Medicare Advantage
Yes