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Coding Guidelines and CPT codes for Radiopharmaceuticals


Radiopharmaceuticals are used in the field of nuclear medicine as tracers in the diagnosis and treatment of many diseases. Many radiopharmaceuticals use technetium-99m (Tc-99m) which has many useful properties as a gamma-emitting tracer nuclide. In the book Technetium a total of 31 different radiopharmaceuticals based on Tc-99m are listed for imaging and functional studies of the brain, myocardium, thyroid, lungs, liver, gallbladder, kidneys, skeleton, blood and tumors.

When radiopharmaceuticals are injected into the body, they emit a radioactive signal which can be traced with special cameras or computers. The amount of radiation a patient is subjected to is about the same as a normal x-ray, but the information gathered is significantly different.

Coders should check the radiopharmaceuticals current HCPCS code description carefully. The codes description defines one unit of service.

1. Most radiopharmaceuticals that have their own code include in the code’s description “per study dose” and include a range of mCi’s (millicurie). These radiopharmaceutical agents should be billed as one unit of service per study. It is not appropriate to bill per mCi for the codes that include per study dose in its HCPC’s description. It would be unusual to have more than 2 units of service for most of the agents with a per study dose or per treatment in its description.

Example: A9503 is defined as Technetium Tc 99m, Medronate, (MDP), diagnostic, per study dose, up to 30 mCi’s). Per study dose, up to 30 millicuries is one unit of service. If the provider administers one to 30mCi of this agent for a study, it should be billed as one unit of service.

2. Some radiopharmaceutical code descriptions are defined as per millicurie (mCi). These agents should be billed per millicurie. The number of mCi’s that were administered to the patient should be the same as the number of services listed in the unit field on the claim.

Example: A9512 is defined as Technetium Tc-99m-Pertechnetate, Diagnostic, per mCi. If you administer 5 mCi of this agent to your patient then 5 would be listed in the units’ field of the claim.

3. NOC radiopharmaceutical codes (A4641, A9699) should be billed with one unit of service. The claim must include the name and total dosage of the agent in item 19 of the CMS 1500 form, or the electronic equivalent for EMC.

The following radiopharmaceuticals will be considered medically necessary when used with the procedures listed below.

A. Technetium (Tc) labeled radiopharmaceuticals:

1. Technetium Tc-99m Arcitumomab (CEA scan), Diagnostic, per study dose, up to 45 mCi's A9568
Immunoscintigraphy, using single-photon emission computed tomography (SPECT) (CPT 78800-78804)

2. Technetium Tc-99m Bicisate (Neurolite®), Diagnostic, per study dose, up to 25 mCi's A9557
Brain imaging (CPT 78600-78607, 78610)

3. Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 10 mCi's, A9551
Parenchymal renal scan. (CPT-4 Codes 78700-78710)
Tumor detection (CPT 78800-78804)

4. Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 25 mCi's, A9539
Lung ventilation (CPT 78579, 78580, 78582, 78597, 78598)
Testicular imaging with vascular flow (CPT 78761)
GFR renal scan. (CPT 78700-78725)
Urinary bladder residual (CPT 78730)
Ureteral reflux (CPT 78740)
CSF study. (CPT 78630-78650)
Brain study. (CPT 78600-78607, 78610)
Shunt patency agent. 500 uCi (CPT 78291, 78645)
First-pass cardiac technique studies (CPT 78481, 78483)
Vascular flow study (CPT 78445)
Cardiac Shunt detection (78428)

5. Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 75 mCi's, A9567
Lung ventilation (CPT 78579, 78580, 78582, 78597, 78598)

6. Technetium Tc-99m Disofenin (Hepatolite, DISIDA) A9510, per study dose, up to 15 mCi's
Hepatobiliary scan agent. (CPT 78226, 78227)

7. Technetium Tc-99m Exametazine (Ceretec®), Diagnostic, per study dose, up to 25 mCi's, A9521
Brain perfusion. (CPT 78600-78607, 78610)

8. Technetium TC-99m Exametazime labeled autologous white blood cells, Diagnostic, per study dose, A9569
Infection detection (CPT 78805-78807)

9. TechnetiumTc-99m Human Serum Albumin A4641
Usual Dosage 2-20 mCi
CSF Leak Study (CPT 78630-78652)
Blood pool agent (CPT 78414-78458)
Lymphatic imaging (CPT 78195)

10. Technetium Tc-99m Iminodiacetic Acid (IDA) A4641
Usual Dosage 5-12 mCi
Hepatobiliary scan agent. (CPT 78226, 78227)

11. Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mCi's, A9540
Lung perfusion agent (CPT 78580, 78582, 78597, 78598)
Peritoneal-Venous Shunt Study (CPT 78291)
Peritoneal cavity imaging prior to intraperitoneal chemotherapy (78800, 78801, 78803)
Cardiac Shunt Detection (CPT 78216, 78428)
Liver imaging (SPECT) (CPT 78201, 78205, 78215)

12. Technetium Tc-99m Mebrofenin (Choletec) Diagnostic, per study dose, up to 15 mCi's A9537
Hepatobiliary scan agent. (CPT 78226, 78227)

13. Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 15 mCi's A9562
Renal scan agent (CPT 78700-78725)

14. Technetium Tc 99m, Medronate, (MDP), diagnostic, per study dose, up to 30 mCi's (A9503)
Bone scan (CPT 78300-78320, 78399)

15. Technetium Tc-99m Oxidronate, Diagnostic, per study dose, up to 30 mCi's. A9561
Bone scan agent (CPT 78300-78320, 78399)

16. Technetium Tc-99m-Pertechnetate, Diagnostic, per mCi, A9512
Thyroid study (CPT 78000-78001, 78006-78007, 78010, 78011, 78015)
Brain death (CPT 78600-78607, 78610)
First-pass cardiac technique studies (CPT 78481, 78483)
Meckel's diverticulum 10-20 mCi (CPT-4 Codes 78261, 78290)
Parathyroid study (CPT 78070)
Parotid or salivary scan (CPT 78230-78232)
Gastric mucosa (CPT 78261, 78290)
Urinary bladder residual (CPT 78730)
Ureteral reflux study (CPT 78740)
Dacryocystography (CPT 78660)
Testicular imaging with vascular flow (CPT 78761)
Peritoneal-Venous Shunt Study (CPT 78291)
Cerebrospinal Fluid study (CPT 78630-78650)

17. Technetium Tc-99m Pyrophosphate (PYP) (Pyrolite®) Diagnostic, per study dose, up to 25 mCi's A9538
Bone (CPT 78300-78320)
Amyloid imaging (CPT 78999)
Myocardial Infarct imaging (78466-78469)

18. Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mCi's, A9560 (Ultra Tag ® or cold pyrophosphate (pyp) +99m technetium),
Cardiac blood pool imaging / Gated Equilibrium studies (78472, 78473, 78494, 78496)
GI bleed study (CPT 78278)
Liver scan (for Hemangioma) (CPT 78201-78206)
Vascular flow study (CPT 78445)
Venous thrombosis imaging (CPT 78457-78458)
Spleen imaging (CPT 78215, 78216, 78185)

19. Technetium Tc-99m, Sestamibi, diagnostic, per study dose, A9500
Cardiac perfusion (CPT 78451-78454)
Parathyroid study (CPT 78070)
Tumor (CPT 78605-78607, 78800-78804)
Breast tumor (CPT 78800, 78801)

20. Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to 20 mCi's A9541
Liver spleen scans. (CPT 78201-78216)
Spleen scan (CPT 78185)
GI bleed studies (CPT 78278)
Bone marrow studies (CPT 78102-78104)
Gastric emptying, gastric emptying with colonic transit studies (CPT 78264, 78299)
Gastroesophageal reflux studies (CPT 78258, 78262)
Ureteral reflux study (CPT 78740)
Urinary bladder residual study (CPT 78730)
Lymphatics & Lymph glands (CPT 78195)
Peritoneal-pleural shunt studies (CPT 78291)

21. Technetium Tc 99m tetrofosmin, diagnostic, per study dose, A9502 (Myoview)
Myocardial perfusion studies (CPT 78451-78454)
Parathyroid study (CPT 78070, 78803)

B. Iodine labeled radiopharmaceuticals:

1. I 123

a. Hippurate (Orthoiodohippurate) A4641
Usual Dosage 150-250 uCi
Renogram. (CPT 78700-78725)

b. Iodine I-123 Sodium iodide capsule(s), Diagnostic A9516 per 100 Microcuries, up to 999 microcuries
Thyroid imaging (CPT 78000-78018, 78020, 78070)

c. Iodine I-123 Sodium Iodide, diagnostic, per millicurie (A9509)
Thyroid imaging (CPT 78000-78018, 78020, 78070)

d. Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries A9582 (AdreView®)
Adrenal imaging/ Pheochromocytoma (CPT 78075)
neuroblastoma imaging. (78800-78804)

e. Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries (DaTscan, ¢-FDA approved 01/14/2011) (A9584).
78607 Brain Imaging, tomographic (SPECT)

2. I 125

a. Iodine-125 sodium iothalamate (Glofil-125®), Diagnostic, per study dose, up to 10 microcuries, A9554
Renogram (CPT 78707-78709, 78725)

b. Iodinated I-125-Serum Albumin, Diagnostic, per 5 microcuries, A9532
Plasma Volume (CPT 78110-78111, 78122)

c. Iodine- 125 Sodium Iodide solution, Therapeutic, per millicurie A9527
Hyperthyroidism or thyroid cancer (CPT 79005)
Intracavitary radiation source application, simple (77761)

3. I 131

a. Hippurate (Orthoiodohippurate) A4641
Usual Dosage 150-250 uCi
Renogram (CPT 78707-78709, 78725)

b. Iobenguane sulfate-Metaiodobenzyl guanidine (MIBG) per 0.5 mCi, A9508
Adrenal imaging/ Pheochromocytoma (CPT 78075)
Neuroblastoma imaging. (78800-78804)

c. Iodine I-131 Sodium Iodide capsule(s), Therapeutic, per mCi, A9517
Hyperthyroidism or thyroid cancer (CPT 79005)

d. Iodine I-131 Sodium Iodide solution, Therapeutic, per mCi, A9530
Hyperthyroidism or thyroid cancer (CPT 79005)

e. Iodine I-131 Sodium Iodide capsule(s), Diagnostic, per mCi, A9528
Thyroid uptake and imaging (CPT 78000-78020, 78803)

f. Iodine I-131 Sodium Iodide solution, Diagnostic, per mCi, A9529
Thyroid uptake and imaging (CPT 78000-78020, 78803)

g. Iodine I-131 Sodium Iodide, Diagnostic, per microcurie (up to 100 microcuries) A9531
Thyroid uptake and imaging (CPT 78000-78020, 78803)

4. Iodine I-131 Tositumomab, (Bexxar®) Diagnostic, per study dose, A9544
Tumor imaging (CPT 78804)

5. Iodine I-131 Tositumomab, (Bexxar®) Therapeutic, per treatment dose, A9545
Radiopharmaceutical therapy, radiolabeled monoclonal antibody by IV infusion (CPT 79403)

6. Iodinated I-131-Serum Albumin, diagnostic, per 5 microcuries, A9524
Plasma Volume (CPT 78110-78111, 78122)
Brain imaging (CPT 78600-78607, 78610)
Pulmonary perfusion imaging (CPT 78580, 78582, 78597, 78598)
Cardiac imaging (CPT 78451-78454)
Tumor imaging (CPT 78800-78804)
Cardiac Blood Pooling imaging (CPT 78472-78473, 78481-78483)

C. Indium labeled Radiopharmaceuticals:

1. Indium IN 111 Capromab Pendetide (ProstaScint®) per study dose, up to 10 mci's (A9507)
Tumor detection (CPT 78800-78804)

2. Indium -111 Diethylenetriamine Pentaacetic acid (DTPA) A4641
Usual Dosage 500 uCi
Cisternography or CSF leak detection, or shunt patency evaluation (CPT 78630-78650)
Gastric emptying (CPT 78264)

3. Indium IN-111 Pentetate Diagnostic, per 0.5 mCi A9548 (MPI INDIUM DTPA IN 111)
Cisternogram (cerebrospinal fluid flow) (CPT 78630)
Cerebrospinal ventriculography (CPT 78635)
CSF Shunt evaluation (CPT 78645)
Cerebrospinal fluid scan (CPT 78647)
CSF Leakage detection and localization (CPT 78650)
Localization of tumor or distribution of radiopharmaceutical agent (78800)

4. Indium-IN-111 Oxyquinoline, Diagnostic, per 0.5 mCi, A9547
Leukocyte labeling (CPT 78805-78807, 78185)
Platelet labeling. (CPT 78190-78191, 78199)

5. Indium-111 Pentetreotide (OctreoScan®), Diagnostic, per study dose, up to 6 millicuries (A9572)
Agent for localization of primary and metastatic neuroendocrine tumors bearing somatostatic receptors (CPT 78075, 78800-78804, 78015-78018)

6. Indium-111 Satumomab pendetide, diagnostic, per study dose, up to 6 mci's (OncoScint®) A4642
Agent for imaging colorectal or ovarian cancers (CPT 78800-78804)

7. Indium-IN-111 Ibritumomab Tiuxetan, Diagnostic, per study dose, up to 5 mCi's A9542 (Zevalin®) and Yttrium-90 Ibritumomab Tiuxetan, Therapeutic, per treatment dose, up to 40 mCi's A9543 (Zevalin®)

a. To report the procedure for determining the biodistribution of Zevalin use procedure code 78804 and the diagnostic imaging agent, A9542- Indium IN-111-Ibritumomab Tiuxetan.

78804 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent (s); whole body, requiring 2 or more days imaging.

This procedure encompasses administration of indium labeled Zevalin followed by whole body radionuclide scanning 2-24 hours and 48-72 hours after the administration of Zevalin. This code may only be reported once, no matter how many scans are performed.

b. To report the radiopharmaceutical therapy using radiolabeled monoclonal antibodies for the treatment of non-Hodgkin's lymphoma use code 79403 and the therapeutic imaging agent, A9543-Yttrium 90 Ibritumomab Tiuxetan.

79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion.

This code includes the physician service, which includes counseling the patient and family, setting up and infusing the radiopharmaceutical and post-procedure time reviewing the appropriate blood work.

8. Indium-111 Hydrochloride (HCL) A4641
Usual dosage 0.1-1.0 mCi
Gastric emptying with colonic transit study (CPT 78299)

9. Indium-111 labeled autologous white blood cells, diagnostic, per study dose (A9570)
Leukocyte labeling (CPT 78805-78807, 78185)

10. Indium in-111 labeled autologous platelets, diagnostic, per study dose (A9571)
Platelet labeling. (CPT 78190-78191, 78199)

D. Miscellaneous Radiopharmaceuticals:

1. Chromium CR-51 Sodium Chromate, Diagnostic, per study dose, up to 250 microcuries A9553
RBC Mass (CPT 78120-78122)
RBC Survival (CPT 78130-78135, 78140)
Platelet Survival. (CPT 78190-78191)

2. Gallium Ga-67 Citrate, Diagnostic, per mCi A9556
Used in scans searching for infections, inflammation, tumors (CPT 78800-78807), and Sarcoidosis (CPT 78999)

3. Chromic Phosphate P-32, suspension, Therapeutic, per mCi A9564
Therapeutic imaging agent for treatment of ovarian cancer. (CPT 79200)
Interstitial radioactive colloid therapy. (CPT 79300, 79445)

4. Sodium Phosphate P-32, Therapeutic, per mCi A9563
Therapeutic imaging agent for treatment of polycythemia vera or thrombocythemia (CPT 79101)

5. Strontium SR-89 Chloride (Metastron®), Therapeutic, per mCi, A9600
Therapeutic for treatment of bone pain due to skeletal metastases. (CPT 79101)

6. Samarium SM-153 Lexidronam (Quadramet®) Therapeutic, per treatment dose up to 150 millicuries (A9604).
Therapeutic for the treatment of pain in patients with confirmed osteoblastic metastatic bone lesions that enhance on radionuclide bone scan (CPT 79101)

7. Thallous Chloride TL-201, diagnostic, per mCi, A9505
Cardiac imaging (CPT 78451-78454)
Parathyroid imaging (CPT 78070)
Tumor imaging (CPT 78800-78804)
Brain imaging (CPT 78607)

8. Xenon Xe-133 Gas, Diagnostic, per 10 mCi's, A9558
Lung study (CPT 78579, 78580, 78582, 78597, 78598)

E. Pet Scan radiopharmaceuticals (A9555, A9552, A9526):

The payment for the radio-tracer or radiopharmaceuticals will be reimbursed for pet scans.

1. Rubidium RB-82 (A9555)

2. Fluorodeoxyglucose (F-18 FDG) (A9552)

3. Ammonia N-13 (A9526)

F. The following agents are no longer marketed in the United States and will be denied. Coverage will be added if the agent(s) become available in the future.


1. A9501 Technetium Tc-99m Teboroxime (Cardiotec®)
2. A9504 Technetium Tc 99m Apcitide (Acu Tect®),
3. A9536 Technetium Tc-99M Depreotide, (Neotect®)
4. A9550 Technetium Tc-99m Sodium Gluceptate (Glucoheptonate®)
5. A9566 Technetium Tc-99m Fanolesomab, (NeutroSpec®)
6. A9546 Cobalt CO-57-/58 Cyanocobalamin
7. A9559 Cobalt CO-57 Cyanocobalamin, oral

G. Use of radiopharmaceuticals is regulated by the Nuclear Regulatory Commission (NRC) under strict procedures and guidelines. Persons administering radiopharmaceuticals should have either a license from the NRC or be credentialed by an institution having a broad license from the NRC.

Reference: LCD Title "Radiopharmaceutical Agents"
 

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