List Cost on Medicare Radiopharma Claims

When billing Medicare for radiopharmaceutical procedure codes, you must list the total acquisition cost on the claim. That's because Medicare contractor Novitas Solutions pays for all radiopharmaceutical procedure codes based on this cost.

This policy is effective for dates of services starting Dec. 1, 2013. Payment allowance will be made at 100 percent of the acquisition cost. Novitas will deny the service if the claim does not list the total acquisition cost. Note the following: 

  • The actual invoice is not required for payment of a radiopharmaceutical procedure, just a listing on the claim. Novitas Solutions, however, will conduct random audits to validate the information on the claim. Novitas will request the actual invoice if it audits your claim.

Report the acquisition cost in Block 19 or Block 24D of the 1500 claim form and in the 2400 loop NTE segment of an EMC claim.

  • Because radiopharmaceutical procedure codes A4641, A9698, A9699, and A9700 are "not otherwise classified" codes, you must report the terminology when billing one of these procedure codes on a claim. Otherwise, Novitas will deny the service.

Need Medicare information? Check the TMA Medicare Resource Center for links to forms, manuals, tips, FAQs, and much more.

Published Feb. 5, 2014

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