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April 8 - Hospital Nuc Med Procedure and Radiopharmaceutical OCE Edits Updated for April 2008

The Centers for Medicsre & Medicaid Services (CMS) has posted revised OCE edits for diagnostic radiopharmaceuticals and nuclear medicine procedures. Included in these edits is the addition of the I-131 therapy HCPCS code A9517 (Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie). The CMS also removed, from the list of CPT codes in the Hospital Outpatient Prospective Payment System (HOPPS) requiring at least one radiopharmaceutical on the claim in order to get full payment, CPT code 78016 Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery).

The CMS made these changes in response to several inquiries regarding the follow-up diagnostic procedure claim, which was returned to provider because there is no diagnostic radiopharmaceutical listed on the claim. This was occurring because according to the 2008 HOPPS Final Rule, all nuclear medicine diagnostic procedure claims must contain at least one diagnostic radiopharmaceutical or the claim will be sent back for correction.

Additionally, the HCPCS code A9530 (Iodine I-131 sodium iodide solution, therapeutic, per millicurie) is under consideration to be included in the OCE edits for next quarter, with a retroactive implementation date if appropriate.

As a reminder, if you are performing a diagnostic procedure using a therapeutic radiopharmaceutical, the Society of Nuclear Medicine (SNM) recommends that you hold the claim for both the therapeutic procedure (79xxx) and the therapeutic radiopharmaceutical until the completion of the diagnostic procedure. Additionally, if your facility identifies other procedures or therapeutic radiopharmaceuticals not listed or bypassed by the CMS, please contact Denise A. Merlino, SNM Coding Advisor, at dmerlino@snm.org. Please include specific examples of therapeutic/diagnostic procedure combinations so that SNM can work with the CMS officials to resolve any additional issues surrounding these hospital edits.

* Download the new Diagnostic Radiopharmaceutical and Nuclear Medicine HCPCS Edits

Source: Society of Nuclear Medicine

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