Health Information Management

Note CMS' payment differences between diagnostic and therapeutic radiopharmaceuticals in 2008

APCs Insider, December 14, 2007

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QUESTION: How will CMS handle payment for radiopharmaceuticals in 2008?

ANSWER: CMS will pay for diagnostic radiopharmaceuticals and therapeutic radiopharmaceuticals differently in 2008. Diagnostic radiopharmaceuticals are one of the categories of items that CMS will package, according to the OPPS final rule. All diagnostic radiopharmaceuticals will have status indicator "N" and be "unconditionally packaged" for 2008. In addition, CMS is creating new edits in the Integrated Outpatient Code Editor (IOCE) that will require providers to report diagnostic radiopharmaceutical HCPCS codes on all claims for diagnostic nuclear medicine procedures. This is similar to the device-procedure edits. If a diagnostic nuclear medicine CPT procedure code is present on a claim, the hospital will also have to submit a diagnostic radiopharmaceutical HCPCS code on the same claim with the same date of service.

In contrast, CMS will continue to separately pay for some therapeutic radiopharmaceuticals. CMS will separately pay for those therapeutic radiopharmaceuticals with a mean per day cost of more than $60 (the separate payment threshold for all drugs). Separately payable therapeutic radiopharmaceuticals will have a status indicator "K" with APC rates based on mean cost data from calendar year 2006.

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