Medicare Radiopharmaceutical Coding, Payment Policy Corrected

July 28, 2010 – The Council on Radionuclides and Radiopharmaceuticals (CORAR) applauded a recent decision by a Medicare administrative to correct coding, coverage and payment policies for radiopharmaceuticals used with myocardial perfusion imaging procedures.

The contractor, Trailblazer Health Enterprises LLC, updated language regarding billing for technetium diagnostic radiopharmaceuticals (A9500) and (A9502) used in multiple myocardial perfusion imaging studies (CPT 78452), which incorrectly limited payment to one dose.

“For the past several years, CORAR members and the Society of Nuclear Medicine (SNM), the American College of Radiology (ACR), the American College of Cardiology (ACC), and the American Society of Nuclear Cardiology (ASNC) have requested that Trailblazer adjust its policy so that providers may bill and be appropriately reimbursed when two technetium heart agent radiopharmaceutical doses are administered consistent with appropriate clinical practice guidelines,” said Michael Guastella, current chairman of the CORAR Healthcare Policy Committee for Reimbursement.

Guastella said the policy in question was inconsistent with good clinical practice and hospital and pharmacy standards. CORAR worked with the medical specialty societies to bring this issue to the attention of CMS. In a letter dated May 21, CORAR brought this issue to the attention of the deputy regional administrator for the Dallas Regional Office of the Centers for Medicare and Medicaid Services (CMS). In response, CMS’s Division of Financial Management and Fee for Service Operations, Region VI consulted with clinical and policy staff at the CMS Central Office and contacted Trailblazer’s medical director. In response to CORAR’s letter the CMS Regional Office communicated that Trailblazer would be withdrawing the language regarding billing for more than one unit of technetium heart agent radiopharmaceutical (A9500) and (A9502) and no longer limit billing to a single dose.

“We believe that this change will allow providers to bill appropriately for the diagnostic radiopharmaceuticals administered while being consistent with Medicare HCPCS coding guidelines, clinical standards and product labeling standards.” said Gail Daubert of ReedSmith, legal counsel to CORAR.

CORAR is an industry trade association comprised of North American manufacturers, developers and suppliers of radiopharmaceuticals and radionuclides primarily used in nuclear medicine and life science research.