Institutional providers billing the fiscal intermediary
HCPCS Description
*A9555 Rubidium Rb-82, Diagnostic, Per study dose, Up To 60 Millicuries
* Q3000 (Deleted effective 12/31/05) Supply of Radiopharmaceutical Diagnostic Imaging Agent, Rubidium Rb-82, per dose
A9526 Nitrogen N-13 Ammonia, Diagnostic, Per study dose, Up To 40 Millicuries
NOTE: For claims with dates of service prior to 1/01/06, providers report Q3000 for supply of radiopharmaceutical diagnostic imaging agent, Rubidium Rb-82. For claims with dates of service 1/01/06 and later, providers report A9555 for radiopharmaceutical diagnostic imaging agent, Rubidium Rb-82 in place of Q3000.
Physicians / practitioners billing the carrier:
*A4641 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Not Otherwise Classified
A9526 Nitrogen N-13 Ammonia, Diagnostic, Per study dose, Up To 40 Millicuries
A9555 Rubidium Rb-82, Diagnostic, Per study dose, Up To 60 Millicuries
NOTE: Effective January 1, 2008, tracer code A4641 is not applicable for PET Scans.
The following tracer codes are applicable only to Procedure 78459, 78608, 78811-78816. They can not be reported with any other code:
Institutional providers billing the fiscal intermediary:
* A9552 Fluorodeoxyglucose F18, FDG, Diagnostic, Per study dose, Up to 45 Millicuries
* C1775 (Deleted effective 12/31/05) Supply of Radiopharmaceutical Diagnostic Imaging Agent, Fluorodeoxyglucose F18, (2-Deoxy-2-18F Fluoro-D-Glucose), Per dose (4-40 Mci/Ml)
**A4641 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Not Otherwise Classified
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NOTE: For claims with dates of service prior to 1/01/06, OPPS hospitals report C1775 for supply of radiopharmaceutical diagnostic imaging agent, Fluorodeoxyglucose F18. For claims with dates of service 1/01/06 and later, providers report A9552 for radiopharmaceutical diagnostic imaging agent, Fluorodeoxyglucose F18 in place of C1775.
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** NOTE: Effective January 1, 2008, tracer code A4641 is not applicable for PET Scans.
Physicians / practitioners billing the carrier:
A9552 Fluorodeoxyglucose F18, FDG, Diagnostic, Per study dose, Up to 45 Millicuries
*A4641 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Not Otherwise Classified
CODING TIPS: Billing for Radiopharmaceuticals
The Level ll HCPCS codes listed below represent the most prevalent options to describe radiopharmaceuticals (RPs) utilized in PET imaging. Arguably, the most commonly submitted choice would be that describing the material used for oncologic imaging, which is
A9552.
A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 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
A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries
Hospitals would assign revenue code 0343 with the chosen code. Under the hospital outpatient prospective payment system (OPPS), all have been assigned the “N” status indicator, which means that they are paid under the OPPS but payment is packaged into payment for other services, including outliers. Therefore, there is no separate payment.
While there are four discrete code choices available for assignment describing completely different materials, there is a common thread in each of the descriptors. That is, any of the codes would only be submitted one time for any one patient exam, regardless of the amount of radioactivity administered. The phrase “per study dose” reinforces this point.
Different payers handle reimbursement for RPs differently. Medicare, for example, packages them when they are submitted on hospital claims for outpatient services. Physicians also may submit these codes to Medicare—but only when the practice or group actuallyincurs the expense of purchasing or procuring the RPs. Usually, an invoice is also required when billing for these items (for Medicare on the professional fee side), but again, this may vary from one Medicare contractor to the next. Reimbursement from non-Medicare payers also varies. Providers and facilities should investigate payer-specific rules and requirements before they bill for these items in order to avoid claim rejections and/or denials.
The clinical portion of this report states “initial staging,” which would indicate that modifier PI (read as “pea-eye”) would be assigned with the appropriate CPT code for the imaging procedure (listed further below).
The Medicare Claims Processing Manual, Chapter 13, subsection 60.16 (at http://www.cms.gov/manuals/downloads/clm104c13.pdf) summarizes the billing and coverage changes for PET scans that took effect for services on or after April 3, 2009. Included there is the following modifier PI description: PET or PET/ CT to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.
The procedure section refers to a PET/CT exam and also to the administration of 16.1 mCi (millicuries) of 18F-FDG—the radiopharmaceutical used for oncologic PET imaging. As indicated in the documentation, FDG stands for fluorodeoxyglucose. Simply, glucose is a sugar that is found in tumors. As such, if labeling this “sugar” with a radioactive material, one is able to track/see and image the location of the tumor.
The FDG is defined by the following Level ll code, which may only be submitted by the entity that purchases it. Depending upon the site of service, this could be the hospital or the physician practice.
A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
If billing for the hospital, revenue code 0343 would be assigned in addition to A9552. If billing for the practice, no revenue code is required.
In the documentation, there is poor delineation of the anatomic area(s) scanned. Best practice would be to use language that correlates to CPT options, such as limited area, skull base to midthigh or whole body. As there is ambiguity in what all was imaged, nominally this would be defined by a limited area PET or PET/CT code. As such, one of the following lower-valued codes would be assigned.
78811 PET imaging, limited area (e.g., chest, head/neck)
78814 PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; limited area (e.g., chest, head/neck)
To be able to assign higher-paid code 78812 or 78815, the physician dictation should contain clear language that correlates to the CPT code description of “skull base to mid thigh.” If less than this was imaged, the report would be better framed by saying “a limited area PET (or PET/CT) was performed.” The lack of such documentation leads to ambiguity and confusion for those attempting to assign the correct CPT code.
FDG PET update
Effective for claims with dates of service on or after June 11, 2013, Medicare will accept and pay for FDG PET oncologic claims billed to inform initial treatment strategy or subsequent treatment strategy for suspected or biopsy proven solid tumors for all oncologic conditions without
• Q0 modifier: Investigational clinical service provided in a clinical research study that is in an approved clinical research study (institutional claims only); requiring the following:
• Q1 modifier: routine clinical service provided in a clinical research study that is in an approved clinical research study (institutional claims only);
• V70.7: Examination of participant in clinical research; or
• Condition code 30 (institutional claims only).
Effective for dates of service on or after June 11, 2013, MACs will use the following messages when denying claims in excess of three for PET FDG scans for subsequent treatment strategy when the –KX modifier is not included, identified by CPT codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier –PS, HCPCS A9552, and the same cancer diagnosis code:
• Claim Adjustment Reason Code (CARC) 96: “Non-Covered Charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”
• Remittance Advice Remarks Code (RARC) N435: “Exceeds number/frequency approved/allowed within time period without support documentation.”
• Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.
• Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file. MACs will not search their files to adjust claims processed prior to implementation of CR8739.
However, if you have such claims and bring them to the attention of your MAC, the MAC will adjust such claims if appropriate.
