Even though a procedure or drug is packaged, the isotope code should still be reported

Q.

With most common isotopes being considered packaged, would it be best practice to not bill the isotope to Medicare at all or bill as you would with other things, such as contrast, that would not be reimbursed? It seems I have been told in the past to bill it even though there would be a denial of payment. However, if that is not the case what would you recommend? 

A.

Medicare tells us that, even though a procedure or drug is packaged, the code should be reported anyway. This includes radiopharmaceuticals. These codes, even though not separately paid, are used for future rate setting by letting Medicare know everything that is normally involved in a procedure.

The Medicare Claims Processing Manual, Chapter 4, Section 10.4 has the following:

“If a claim contains services that result in an APC payment but also contains packaged services, separate payment for the packaged services is not made since payment is included in the APC. However, charges related to the packaged services are used for outlier and Transitional Corridor Payments (TOPs) as well as for future rate setting. Therefore, it is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately paid or is packaged.”

Each year Medicare goes through their Outpatient Prospective Payment System (OPPS) claims from two years previous and pulls together the “Cost Statistics” file. It shows how many claims were filed by CPT® code by OPPS hospitals, what the lowest cost was on a claim, what the highest cost was, and what were the median and geometric mean costs. That’s how they come up with a fee schedule amount for the next year.

An example of that can be found in nuclear medicine, CPT code 78452.

You’ll notice that in 2018 one hospital claimed total costs of only $331.75, while another hospital claimed total costs of $4616.88 for 78452. The median cost was $1,298.92, while the geometric mean cost was $1,259.43. So, the payment for CPT code 78452 in 2020 was: $1,272.05.

The hospital which stated that CPT code 78452 only “cost” them $331 probably didn’t include all their costs, such as the expense of the radiopharmaceutical and its code, the stress agent code, or the stress testing code (93017), etc. So, you can see why it is important to include all the costs even though you know the codes will be denied. If there is no code, the cost should be included under an appropriate revenue code.