The purpose of this article is to provide all J-12 contract areas with the appropriate instructions for reporting radiopharmaceuticals used in conjunction with diagnostic or therapeutic services such as SPECT studies or cardiovascular stress testing procedures.

In accordance with CMS Change Request 4053, effective for dates of service January 1, 2005, and after, Medicare Part B radiopharmaceutical payment allowance limits are “not” subject to the Average Sales Price (ASP). CMS also indicated that contractors were to utilize the payment methodology in place under Medicare Part B as of November 2003.

Highmark Medicare Services payment methodology for radiopharmaceuticals is based upon the instructions outlined in Publication 100-4, Chapter 13, Section 50.1 of the IOM. This instruction states that all radionuclide’s used in connection with a covered diagnostic or therapeutic study should be reimbursed separately and paid on a “by report” basis which has been historically known as the acquisition cost or the manufacturer’s invoice price.

Therefore, in order to receive the appropriate payment allowance for this service, providers must report the acquisition cost of the radionuclide in the Claim Note Segment (Loop 2300, Segment NTE, Data Element 02 (2300-NTE02) to report at the Claim Level or Loop 2400, Segment NTE, Data Element 02 (2400-NTE02) to report at the Line Level) of the X12N 837 Claim transaction for electronic claims. For paper claims, the acquisition cost of the radionuclide should be reported in Block #19 or Block 24D of the 1500 claim form If this information is not reported, the service may be denied for insufficient information.

To have denied services considered for payment, a new claim may be submitted for the radiopharmaceutical with the required information. Also, providers have the opportunity to have claims reopened for missing information. Reopenings may be conducted by calling Highmark Medicare Services at 1-866-488-0551 or by writing to Highmark Medicare Services at the following P.O. Box Offices: