Question:

What is the Medicare policy for physician office radiopharmaceutical payments?

Answer:

In the physician office setting, radiopharmaceuticals (RPs) are not subject to average sales price (ASP) methodology for payment. Increasingly, Medicare contractors are switching to payments for RPs at invoice cost, so you may want to ask your RP provider to incorporate the cost of transportation with the line item cost of the RP to facilitate communicating the full RP cost to the payer. Invoices may be required.

Note that Medicare contractors have discretion in establishing rates, as all RPs are currently carrier-priced in this setting. Check with your Medicare contractor for local allowable rates. As always, code and bill for RPs and drugs regardless of payment status by the payers as this is proper coding per the introductory section of CPT®.


CPT® is a registered trademark of the American Medical Association.

This question was answered in the 2018 edition of our Nuclear Medicine & PET Coder. For more hot topics relating to cardiology and radiology services, please view our store, or call us at 1.800.252.1578 ext. 2.

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CPT® copyright 2021 American Medical Association (AMA). All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.