Nip Nuclear Med Troubles in the Bud With These RP Tips

Plus: Considering Lexiscan? Discover which HCPCS code applies.

Rumor has it that recovery audit contractors have been scrutinizing radiopharmaceutical claims. And with special rules regarding units, invoices, and more, it's no wonder these are a common spot for errors.

You can be sure your practice makes the grade by following these guidelines to clean radiopharmaceutical and nuclear medicine claims.

Choose the Appropriate RP Code

Filing a claim that includes a radiopharmaceutical (RP) requires a lot more than choosing the proper HCPCS code for the RP. But that doesn't mean choosing the proper code is a snap.

Problem: One auditor found that a practice's coders consistently reported A4641 (Radiopharmaceutical, diagnostic, not otherwise classified) instead of the code that described the specific RP used, such as A9505 (Thallium Tl-201 thallous chloride, diagnostic, per millicurie).

Solution: Be specific. If a HCPCS code describes the particular drug used, you must use that code instead of something more general.

For example, codes A9502 (Technetium Tc-99m tetrofosmin, diagnostic, per study dose, up to 40 millicuries) for Myoview and A9500 (Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries) for Cardiolite are two codes that Sarah Tupper, CMC, coder for Central New York Cardiology in Utica, often sees.

Other codes you may need to consider for your claims include A9505 and low osmolar contrast codes Q9965-Q9967.

Note that the same rule about reporting a specific code when available applies to stress agents, too. For instance, if you use adenosine, you should use the appropriate adenosine code, such as J0152 (Injection, adenosine for diagnostic use, 30 mg).

RP or Stress Agent Unlisted? Not Just Any Code Will Do

If you use an RP or agent that doesn't have its own code, do some research to discover the proper code to report.

For example, Tupper's practice is looking into using the stress agent Lexiscan, which doesn't have its own code, Tupper notes. For Lexiscan you would report J3490 (Unclassified drugs), Tupper says.

This matches Society of Nuclear Medicine (SNM) advice to report J3490 for Lexiscan in the freestanding facility and physician office setting (www.snm.org/index.cfm?PageID=7701&RPID=1981).

Hospitals take heed: Note that starting Oct. 1, "HCPCS code C9244 (Injection, regadenoson, 0.4mg) should be used for billing Lexiscan to Medicare in the hospital outpatient setting only," according to SNM.

Pay Attention to 'Per Dose' Units

Choosing the appropriate number of units for most RPs seems simple because the descriptors specify "per study dose."

So, for example, if the cardiologist uses 40 millicuries of Myoview for a myocardial perfusion study, you would choose one unit of A9502, which specifies "per study dose, up to 40 millicuries."

But real-life tests don't always prove so easy to code. For example, if the cardiologist uses sestamibi (A9500, ... per study dose, up to 40 millicuries) during both the rest and stress portions of a test, and the total comes to 50 mg, you should report two units for many payers.

Reason: According to the Medicare Claims Processing Manual, Chapter 17, "Drugs and Biologicals," if the drug dose isn't a multiple of the dose specified in the HCPCS code long descriptor, you should round up (www.cms.hhs.gov/manuals/downloads/clm104c17.pdf).

TrailBlazer note: You may have to send documentation to support billing multiple units, depending on your payer. Your payers typically should recognize the rest imaging to be one study and the stress imaging to be a second study, allowing you to report a "per study" vial for each.

Medicare administrator TrailBlazer, however, has its own rules and "considers the two phases (rest and exercise) to meet the description of the perfusion study. If more than one unit is billed, medical records must support more than 40 mCi were administered and be made available upon request" (www.trailblazerhealth.com/Publications/Fee%20Schedule/2008RadiopharmaceuticalInvoiceRequirements.pdf).

Another exception: Although rare, you also may encounter payers who want you to bill one unit per study dose regardless of the actual amount used. Noridian Medicare told providers that "when a provider exceeds the 'up to' dosage on one study for a radiopharmaceutical Healthcare Common Procedure Coding System (HCPCS) code that has a description of 'per study dose' or 'per treatment,' the provider should only bill one unit" (www.noridianmedicare.com/macj3b/news/bulletins/docs/medicare_b_news_issue_242_january_4_2008.pdf).

Invest in Solid Invoice Organization

When you're dealing with RP claims, another detail you can't ignore is that you must have an invoice on file in case the payer requests it. And for certain drugs, the payer requires you to send an invoice with the claim.

For example, if you use Myoview (A9502) during a stress test, you may need to send an invoice for the RP along with your claim, says Nancy Bui, medical billing specialist with Cardiac Care Associates in Fairfax, Va.

Consider Charging No-Shows for RPs

Many RPs have a short shelf life, so if a patient doesn't show for an appointment, you can be left with an unusable RP that costs you a lot of money. You can't bill this unused RP to insurance, so consider instituting a policy charging the patient a missed appointment fee.

Remember: You should inform patients of the policy and have approval for the fees in the contracts your practice has with payers before charging the patient.