Corporate

March 7, 2013 - Revised: 10.31.13

Radiopharmaceutical Drugs

Effective April 15, 2013, unless the Centers for Medicare & Medicaid Services (CMS) has established pricing, claims for radiopharmaceutical drugs submitted with HCPCS codes A9500 – A9700, must include either invoice information or a copy of the actual invoice for pricing purposes.

For electronic claims, report this information in the electronic Documentation Field (Loop 2300, NTE Segment (header level) or Loop 2400, NTE Segment (line level)). If you are approved to submit paper claims, submit this information in Item 19 of the CMS-1500 claim form and provide a copy of the actual invoice.

  • The name of the drug and the exact dosage administered must appear in the Documentation Field.
    • If the charge matches the actual invoice cost, note "Actual Invoice Cost" in the Documentation Field.
    • If you are submitting a charge greater than the actual invoice cost, please include the following information in the Documentation Field, using these abbreviations:
      • Des = Description/Name of agent (e.g., Des=TC99m MDP)
      • QS = Quantity shipped (e.g., QS=100 mci)
      • TA = Total amount charged for quantity shipped (e.g., TA=$57.40)
      • UP = Unit Price (e.g., UP = $0.57 per mci) (Optional)
      • DG = Dosage given (e.g., DG=25 mci)
  • In lieu of submitting the invoice information, you may use the Paperwork (PWK) process and send a copy of the invoice via fax or mail. Click for Details on the PWK process.

Claims for radiopharmaceutical drugs received without the invoice information or the actual invoice may be denied or delayed.

CMS has established pricing information for some radiopharmaceuticals. Those radiopharmaceuticals established reimbursement amounts do not require the information noted above. Those drugs with an established reimbursement are available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.htmlExternal Website


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