A Codes - familiar with billing


True Blue
Smithtown, NY
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is anyone familiar with billing out a9555 and a9552 pharm codes? i need a little help (i.e. units i can bill for specific cardiology procedures)?


Moore, OK
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I hope you have room for a bucket of headaches.

A9555 is Rubidium-82 and is used in conjunction with PET myocardial perfusion studies [78491 and 78492]. A9552 is commonly called FDG [fluorodeoxyglucose F18] and is used in conjunction with PET cardiac metabolic studies [78459].

For Medicare, coverage, pricing and coding policy is left to the MACs. In general, the MACs require that you report a "per study" dose at your exact invoice cost and may require claims to be accompanied by an invoice.

Rubidium-82 does not come in vials, bottles or other containers. Rb-82 is produced by a generator. The rubidium is generated at the time of the study and is infused directly into the patient. There is usually a "dose" generated at rest and a "dose" generated at stress. Each dose is measured in millicuries [mCi] which are added together to determine the number of mCi used for the study. [This is going to get complicated].

Invoice costs are a challenge. Our practice pays a monthly rental for the rubidium generator. At the end of the month, we total the number of "per study" doses used and divide that into the monthly rental cost to determine our "invoice" cost for a per study dose. Obviously, it will vary somewhat from month to month. [More on this below].

Using more than 60 mCi per study becomes an issue. Up to 60 mCi is reported on claims as 1 unit with an invoice cost equal to the monthly per study calculation. If > 60 mCi are used during a study, 2 units should be reported, but this hits against an medically unlikely edit [MUE] which is apparently set at 1 for A9555. [CMS started publishing MUEs on 10/1/2008, but I haven't looked at them yet]. Your practice will have to decide how to handle this issue.

Under our previous Medicare carrier [Pinnacle] we delayed billing A9555s until the end of the month when our exact invoice costs were determined. During the month, we reported the PET study and after the end of the month, we filed claims for A9555. Our current MAC [TrailBlazer] established a per study allowable for A9555. They will pay the lesser of the allowed amount or our invoice costs. So far, our invoice costs are above the allowable, so we are able to report A9555 with the claim for the PET study. If our invoice costs fall below the allowable [or we suspect that they will], we will have to revert to the previous billing method so that we stay in compliance.

There are also issues with FDG.

There are more considerations when dealing with Medicare Advantage plans and commercial payers.

This is a bit long. For more, contact me direct at tdavis@ocaheart.com

Terry Davis