Health Information Management

Q&A: Report diagnostic radiopharmaceutical HCPCS code with nuclear medicine procedure

APCs Insider, August 22, 2008

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QUESTION: We perform a therapeutic thyroid treatment (code 79005) with radiopharmaceutical Iodine I-131 (A9517). Seven to 10 days after the treatment, the patient returns for a diagnostic scan (code 78018) only. Physicians use no additional radiopharmaceuticals during the second visit. Software edits in place for the second visit indicate that the “claim lacks radiopharmaceutical.” If we don’t use one, why must we bill one?

ANSWER.  The calendar year (CY) 2008 OPPS final rule implemented new requirements when billing for separately payable nuclear medicine procedures. Transmittal 1417, CR 5912, summarizes the new requirements:

Effective January 1, 2008, the I/OCE will begin editing for the presence of a diagnostic radiopharmaceutical HCPCS code when a separately payable nuclear medicine procedure is present on a claim. Hospitals are required to submit the diagnostic radiopharmaceutical on the same claim as the nuclear medicine procedure. Hospitals are also instructed to submit the claim so that the services on the claim each reflect the date the particular service was provided. Therefore, if the nuclear medicine procedure is provided on a different date of service from a diagnostic radiopharmaceutical, the claim will contain more than one date of service. The nuclear medicine procedure-diagnostic radiopharmaceutical edits are available on the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/under downloads. Failure to pass these edits will result in the claim being returned to the provider.

CPT code 78018 is on the list of procedures requiring you to report a radiopharmaceutical. Report HCPCS code A9517 on the claim with code 78018 for the claim to be accepted for payment. We suggest that each individual facility create a process to ensure that both codes are billed on the same claim.



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