Contrast Agents and Radiopharmaceuticals 2017

Transcription

1 Contrast Agents and Radiopharmaceuticals 207 Covered: Code Code Description Allow with Code(s) Code Description Max Units A464 Radiopharmaceutical, diagnostic, not otherwise classified n/a Invoice Req'd A9500 A9502 A9503 A9505 A9507 A9508 Technetium Tc-99m, Sestamibi, diagnostic, per study dose Technetium Tc-99m tetrofosmin, diagnostic, per study dose Technetium Tc-99m, Medronate, (MDP), diagnostic, per study dose, up to 30 mci's Thallous Chloride TL-20, diagnostic, per mci Indium IN Capromab Pendetide (ProstaScintâ) per study dose, up to 0 mci's Iobenguane sulfate- Metaiodobenzyl guanidine (MIBG) Myocardial perfusion studies Parathyroid study , Tumor imaging Myocardial perfusion studies Parathyroid study Bone scan Cardiac imaging Parathyroid imaging Tumor imaging Brain imaging Tumor detection Adrenal imaging Neuroblastoma imaging A9509 Iodine I-23 Sodium Iodide, diagnostic, per millicurie , 78020, Thyroid imaging 5 A950 Technetium Tc-99m Disofenin (Hepatolite, DISIDA), per study dose, up to 5 mci's 78226, Hepatobiliary scan agent of 7

2 A952 A956 A9520 A952 Technetium Tc-99m- Pertechnetate, Diagnostic, per mci Iodine I-23 Sodium iodide capsule(s), Diagnostic per 00 Microcuries, up to 999 microcuries Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 millicurie Technetium Tc-99m Exametazine (Ceretec ), Diagnostic, per study dose, up to 25 mci s Thyroid study , 7860 Brain study 7848, First-pass cardiac technique studies 7826 Gastric mucosa imaging Intestine imaging 7829 Peeritoneal-Venous shunt study Parathyroid study Parotid or salivary scan Urinary bladder residual Ureteral reflux study Cerebrospinal fluid flow, imaging Dacryocystography 7876 Testicular imaging with vascular flow , 78020, Invoice Req'd Thyroid imaging Lynph Node Imaging , 7860 Brain perfusion , 7822 Plasma Volume 5 A9524 A9528 A9529 A953 Iodinated I-3-Serum Albumin, diagnostic, per 5 microcuries Iodine I-3 Sodium Iodide capsule(s), Diagnostic, per mci Iodine I-3 Sodium Iodide solution, Diagnostic, per mci Iodine I-3 Sodium Iodide, Diagnostic, per microcurie (up to 00 microcuries) , 7860 Brain imaging Pulmonary perfusion imaging Cardiac imaging Tumor imaging , Cardiac Blood Pooling imaging , Thyroid uptake and imaging , Thyroid uptake and imaging , Thyroid uptake and imaging 80 2 of 7

3 A9537 A9538 A9539 A9540 Technetium Tc-99m Mebrofenin (Choletec ) Diagnostic, per study dose, up to 5 mci's Technetium Tc-99m Pyrophosphate (PYP) (Pyrolite ) Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 25 mci's Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 0 mci s 78226, Hepatobiliary scan agent Bone and/or joint imaging Myocardial infarct imaging Lung ventilation 7876 Testicular imaging with vascular flow GFR renal scan Urinary bladder residual Ureteral reflux CSF study , 7860 Brain study 7829, Shunt patency agent. 500 uci 7848, First-pass cardiac technique studies Vascular flow study Cardiac shunt detection Lung perfusion agent 7829 Peritoneal-Venous Shunt Study 7826, Cardiac Shunt Detection 7820, 78205, 7825 Liver imaging 78800, 7880, Tumor imaging 7885 Spleen imaging Bone marrow studies Liver, spleen imaging Urinary bladder residual study A954 A9542 Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to20 mci's Indium-IN- Ibritumomab Tiuxetan, Diagnostic, per study dose, up to 5 mci's 7895 Lymphatics & Lymph glands 78258, Gastroesophageal reflux studies Gastric emptying, gastric 78264, 78265, emptying with colonic transit studies GI bleed studies 7829 Peritoneal-pleural shunt studies Ureteral reflux study Radiopharmaceutical localization of tumor 3 of 7

4 A9547 A9548 A955 A9553 A9554 A9556 A9557 A9558 A9560 A956 A9562 Indium-IN- Oxyquinoline, Diagnostic, per 0.5 mci Indium IN- Pentetate (MyoScint ) Diagnostic, per 0.5 mci Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 0 mci's Chromium CR-5 Sodium Chromate, Diagnostic, per study dose, up to 250 microcuries Iodine-25 Sodium Iothalamate (Glofil-25 ), Diagnostic, per study dose, up to 0 microcuries Gallium Ga-67 Citrate, Diagnostic, per mci Technetium Tc-99m Bicisate (Neurolite ), Diagnostic, per study dose, up to 25 mci's Xenon Xe-33 Gas, Diagnostic, per 0 mci s Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mci s (Ultra Tag or cold pyrophosphate (pyp) +99m technetium) Technetium Tc-99m Oxidronate, Diagnostic, per study dose, up to 30 mci's Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 5 mci's , 7885 Leukocyte labeling Platelet labeling 78630, 78635,78645, Cerebrospinal fluid flow, imaging CSF leakage and detection Localization of tumor Parenchymal renal scan Tumor detection RBC Mass , 7840 RBC Survival Platelet Survival , Renogram Tumor imaging , 7860 Brain imaging Pulmonary perfusion imaging , 78473, 78494, Cardiac blood pool imaging / Gated Equilibrium studies GI bleed study Liver scan (for Hemangioma) Vascular flow study Venous thrombosis imaging 7825, 7826, 7885 Spleen imaging Bone scan agent Renal scan agent 4 of 7

5 A9567 Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 75 mci s Lung ventilation A9569 Technetium TC-99m Exametazime labeled autologous white blood cells, Diagnostic, per study dose Infection detection A9570 A957 A9572 A9582 Indium- labeled autologous white blood cells, diagnostic, per study dose Indium in- labeled autologous platelets, diagnostic, per study dose Indium- Pentetreotide (OctreoScan ), Diagnostic, per study dose, up to 6 millicuries Iodine i-23 Iobenguane, diagnostic, per study dose, up to 5 millicuries AdreView ) , 7885 Leukocyte labeling Platelet labeling Adrenal imaging Thyroid imaging Radiopharmaceutical localization of tumor Adrenal imaging Neuroblastoma imaging 5 of 7

6 Non-Covered Services: Code A955* A9526 Contrast agents billed in conjunction with an MRI Radiopharmaceuticals billed in conjunction with a PET scan Materials billed with a CT or other radiographic study not mentioned above Non-Ionic Contrasts or low osmolar contrast material Isotopes for therapeutic purposes are not covered under these payment rules Non-Covered Code Description Choline c-, diagnostic, per study dose up to 20 millicuries Nitrogen n-3 ammonia, diagnostic, per study dose, up to 40 millicuries A9552 Fluorodeoxyglucose f-8 fdg, diagnostic, per study dose, up to 45 millicuries A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries A9576 Injection, gadoteridol, (prohance multipack), per ml A9577 Injection, gadobenate dimeglumine (multihance), per ml A9578 Injection, gadobenate dimeglumine (multihance multipack), per ml A9579 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS A9580 Sodium fluoride f-8, diagnostic, per study dose, up to 30 millicuries A958 Injection, gadoxetate disodium, ml A9585 Injection, gadobutrol, 0. ml A9587* Gallium ga-68, dotatate, diagnostic, 0. millicurie A9588* Fluciclovine f-8, diagnostic, millicurie A9586 Florbetapir f8, diagnostic, per study dose, up to 0 millicuries A9597* Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not Positron th i emission l ifi d tomography radiopharmaceutical, diagnostic, for non-tumor identification, not A9598* otherwise classified A9698 Non-radioactive contrast imaging material, noc, per study A9700 Supply of injectable contrast material for use in echocardiography, per study C946 Choline C, diagnostic, per study dose Q995 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml Q9953 Injection, iron-based magnetic resonance contrast agent Q9954 Oral magnetic resonance contrast agent, per ml Q9958 High osmolar contrast material, up to 49 mg/ml iodine concentration, per ml Q9959 High osmolar contrast material, mg/ml iodine concentration, per ml Q9960 High osmolar contrast material, mg/ml iodine concentration, per ml Q996 High osmolar contrast material, mg/ml iodine concentration, per ml Q9962 High osmolar contrast material, mg/ml iodine concentration, per ml Q9963 High osmolar contrast material, mg/ml iodine concentration, per ml Q9964 High osmolar contrast material, 400 or greater mg/ml iodine concentration, per Q9965 Low osmolar contrast material, mg/ml iodine concentration, per ml 6 of 7

7 Q9966 Low osmolar contrast material, mg/ml iodine concentration, per ml Q9967 Low osmolar contrast material, mg/ml iodine concentration, per ml Q9968 Methylene blue, isosulfan blue), mg Q9982 Flutemetamol F8, diagnostic, per study dose, up to 5 millicuries Q9983 Florbetaben f8, diagnostic, per study dose, up to 8. millicuries *Added of 7