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Nuclear Medicine and Charging for Radiopharmaceuticals

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The Ambulatory Payment Classification (APC) used to reimburse for Nuclear Medicine procedures under The Outpatient Prospective Payment System (OPPS) does not include the cost of many radiopharmaceutical agents. For this reason, hospitals need to know when they must generate separate charges for radiopharmaceuticals or isotopes that are used in conjunction with these procedures.

Radiopharmaceuticals

The hospital charge master should contain specific charges for all radiopharmaceuticals that are used in conjunction with Nuclear Medicine procedures.

The table below presents the 2006 HCPCS Level II for radiopharmaceuticals. The status indicator and the applicable UB-92 revenue codes are also included. The status indicator is part of OPPS and represents whether payment is by APC, by fee schedule, or not paid. The UB-92 revenue code is a three digit number that describes the type of service provided, e.g. 343 Nuclear Medicine — Diagnostic Radiopharmaceutical, or 344 Nuclear Medicine — Therapeutic Radiopharmaceutical.

For the table below:

** Status Indicator N means that this is an incidental service and not separately paid under OPPS.

** Status Indicator H means that this is a paid under OPPS by one of the following methods:

  1. Separate cost-based Pass-Through payment not subject to coinsurance
  2. Separate cost-based Non-Pass-Through payment
CPT/HCPCS CODE DESCRIPTION STATUS INDICATOR REV CODE
A4641 NM RADIOPHARMACEUTICAL DIAGNOSTIC N 343
A4642 NM SATUMOMAB PENDETIDE PER DOSE DX H 343
A9500 NM TC-99M SESTAMIBI PER DOSE DX H 343
A9502 NM TC-99M TETROFOSMIN PER UNIT DOSE DX H 343
A9503 NM TC-99M MEDRONATE UP TO 30 MCI DX N 343
A9504 NM TC-99M APCITIDE PER STUDY DOSE UP TO 20 MCI DX H 343
A9505 NM THALLOUS CHLORIDE TL-201 PER MCI DX H 343
A9507 NM I-111 CAPROMAB PENDETIDE PER DOSE DX H 343
A9508 NM I-131 PER 0.5 MCI DX H 343
A9510 NM TC-99M DISOFENIN UP TO 15 MCI DX H 343
A9512 NM TC-99M PERTECHNETATE PER MCI DX N 343
A9516 NM I-123 CAPSULE PER 100 UCI DX H 343
A9517 NM I-131 CAPSULE PER MCI TX H 344
A9521 NM TC-99M EXAMETAZINE PER DOSE DX H 343
A9524 NM I-131 SERUM ALBUMIN PER 5 UCI DX H 343
A9526 NM AMMONIA N-13 PER DOSE H 343
A9528 NM I-131 CAPSULE PER MCI DX H 343
A9529 NM I-131 SOLUTION PER MCI DX H 343
A9530 NM I-131 SOLUTION PER MCI TX H 344
A9531 NM I-131 SODIUM PER UCI (UP TO 100 UCI) DX H 343
A9532 NM I-125 SERUM ALBUMIN PER 5 UCI DX H 343
A9536 NM TC-99M DEPREOTIDE PER STUDY DOSE UP TO 35 MCI DX H 343
A9537 NM TC-99M MEBROFENIN PER STUDY DOSE UP TO 15 MCI DX N 343
A9538 NM TC-99M PYROPHOSPHATE PER STUDY DOSE UP TO 25 MCI DX N 343
A9539 NM TC-99M PENTETATE PER STUDY DOSE UP TO 25 MCI DX N 343
A9540 NM TC-99M MACROAGGREGATED ALBUMIN PER STUDY DOSE UP TO 10 MCI DX N 343
A9541 NM TC-99M SULFUR COLLOID PER STUDY DOSE UP TO 20 MCI DX N 343
A9542 NM I-111 IBRITUMOMAB TIUXETAN PER STUDY DOSE UP TO 5 MCI DX H 343
A9543 NM YTTRIUM Y-90 IBRITUMOMAB TIUXETAN PER TREATMENT DOSE UP TO 40 MCI TX H 344
A9544 NM I-131 TOSITUMOMAB PER STUDY DOSE DX H 343
A9545 NM I-131 TOSITUMOMAB PER TREATMENT DOSE TX H 344
A9546 NM COBALT CO-57/58 CYANOCOBALAMIN PER STUDY DOSE UP TO 1 UCI DX N 343
A9547 NM I-111 OXYQUINOLINE PER 0.5 MCI DX H 343
A9548 NM I-111 PENTETATE PER 0.5 MCI DX H 343
A9549 NM TC-99M ARCITUMOMAB PER STUDY DOSE UP TO 25 MCI DX H 343
A9550 NM TC-99M SODIUM GLUCEPTATE PER STUDY DOSE UP TO 25 MCI DX H 343
A9551 NM TC-99M SUCCIMER PER STUDY DOSE UP TO 10 MCI DX H 343
A9552 NM FLUORODEOXYGLUCOSE F-18 FDG PER STUDY DOSE UP TO 45 UCI DX H 343
A9553 NM CHROMIUM CR-51 SODIUM CHROMATE PER STUDY DOSE UP TO 250 UCI DX H 343
A9554 NM I-125 SODIUM IOTHALAMATE PER STUDY DOSE UP TO 10 MCI DX H 343
A9555 NM RUBIDIUM RB-82 PER STUDY DOSE UP TO 60 MCI DX H 343
A9556 NM GALLIUM GA-67 CITRATE PER MCI DX H 343
A9557 NM TC-99M BICISATE PER STUDY DOSE UP TO 25 MCI DX H 343
A9558 NM XENON XE-133 GAS PER 10 MCI DX N 343
A9559 NM COBALT CO-57 CYANOCOBALAMIN ORAL PER STUDY DOSE UP TO 1 UCI DX N 343
A9560 NM TC-99M LABELED RED BLOOD CELLS PER STUDY DOSE UP TO 30 MCI DX H 343
A9561 NM TC-99M OXIDRONATE PER STUDY DOSE UP TO 30 MCI DX N 343
A9562 NM TC-99M MERTIATIDE PER STUDY DOSE UP TO 15 MCI DX H 343
A9563 NM SODIUM PHOSPHATE P-32 PER MCI TX H 344
A9564 NM CHROMIC PHOSPHATE P-32 SUSPENSION PER MCI TX H 344
A9565 NM I-111 PENTETREOTIDE PER MCI DX H 343
A9566 NM TC-99M FANOLESOMAB PER STUDY DOSE UP TO 25 MCI DX H 343
A9567 NM TC-99M PENTETATE AEROSOL PER STUDY DOSE UP TO 75 MCI DX H 343
A9600 NM STRONTIUM-89 PER MCI TX H 344
A9605 NM SAMARIUM-153 LEXIDRONAM 50 MCI TX H 344
A9699 NM RADIOPHARMACEUTICAL THERAPEUTIC N 344