Definity-coding-payment - The International Contrast Ultrasound

2012 Medicare Reimbursement Information Lantheus Medical Imaging
If you have questions regarding reimbursement for Lantheus Medical Imaging products,
call Randy VanCoughnett at 978-436-7995 or email [email protected].
Reimbursement consists of three elements: Coding, coverage and payment.
Coding: There must be a CPT® code or HCPCS code that accurately describes the
service performed and/or the drugs provided.
Coverage: The existence of CPT and/or HCPCS codes used to report the services
performed or items furnished does not guarantee coverage for procedures, supplies or
drugs.
Medicare only covers a procedure, drug or supply when it is medically necessary.
Providers should obtain and follow the policies and guidelines published by Medicare in
the Local and National Coverage Determinations.
Payment: If the proper codes exist and there is coverage established, Medicare must
set a payment amount for the drugs, supplies and or procedures in order for providers to
receive payment. Most payment amounts are determined by CMS nationally. There are
differences in procedure payment amounts from region to region to reflect geographic
differences in provider costs.
Documentation: When radiopharmaceuticals or contrast agents are reported providers
must document in the medical record the name of the drug and the amount
administered.
Lantheus Medical Imaging, Inc. cannot guarantee coverage or payment for products or
procedures. Payer policies can vary widely. For more specific information contact the
payer directly in order to obtain up to date coverage, coding and payment information.
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2012 Medicare Reimbursement Information Lantheus Medical Imaging
DEFINITY® Vial for (Perflutren Lipid Microsphere) Injectable Suspension
INDICATIONS
Activated DEFINITY® (Perflutren Lipid Microsphere) Injectable Suspension is indicated
for use in patients with suboptimal echocardiograms to opacify the left ventricular
chamber and to improve the delineation of the left ventricular endocardial border.
CONTRAINDICATIONS
Do not administer DEFINITY® to patients with known or suspected right-to-left, bidirectional or transient right-to-left cardiac shunts, by intra-arterial injection, or to patients
with known hypersensitivity to perflutren.
IMPORTANT SAFETY INFORMATION
WARNING: Serious Cardiopulmonary Reactions
Serious cardiopulmonary reactions, including fatalities, have occurred uncommonly
during or following perflutren-containing microsphere administration [See WARNINGS
AND PRECAUTIONS (5.1)]. Most serious reactions occur within 30 minutes of
administration.
Assess all patients for the presence of any condition that precludes DEFINITY®
administration [See CONTRAINDICATIONS (4)].
Always have resuscitation equipment and trained personnel readily available.
In post marketing use, rare but serious cardiopulmonary or anaphylactoid reactions have
been reported during or shortly following perflutren-containing microsphere
administration [See ADVERSE REACTIONS (6)]. The risk for these reactions may be
increased among patients with unstable cardiopulmonary conditions [See Postmarketing
Experience (6.2)]. It is not always possible to reliably establish a causal relationship to
drug exposure due to the presence of underlying cardiopulmonary disease.
Please see full prescribing information on pages 11-13, including boxed
WARNING regarding serious cardiopulmonary reactions.
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2012 Medicare Reimbursement Information Lantheus Medical Imaging
ABLAVAR® gadofosveset trisodium
INDICATIONS:
ABLAVAR® is indicated for use as a contrast agent in magnetic resonance angiography
(MRA) to evaluate aortoiliac occlusive disease (AIOD) in adults with known or suspected
peripheral vascular disease.
CONTRAINDICATIONS:
History of a prior allergic reaction to a gadolinium-based contrast agent.
IMPORTANT SAFETY INFORMATION:
WARNING: NEPHROGENIC SYSTEMIC FIBROSIS (NSF)
Gadolinium-based contrast agents (GBCAs) increase the risk for NSF among patients
with impaired elimination of the drugs. Avoid use of GBCAs in these patients unless the
diagnostic information is essential and not available with non-contrasted MRI or other
modalities. NSF may result in fatal or debilitating fibrosis affecting the skin, muscle and
internal organs.
• The risk for NSF appears highest among patients with:
• chronic, severe kidney disease (GFR < 30 mL/min/1.73m2), or
• acute kidney injury.
• Screen patients for acute kidney injury and other conditions that may reduce renal
function. For patients at risk for chronically reduced renal function (e.g. age > 60 years,
hypertension or diabetes), estimate the glomerular filtration rate (GFR) through
laboratory testing.
• For patients at highest risk for NSF, do not exceed the recommended ABLAVAR dose
and allow a sufficient period of time for elimination of the drug from the body prior to
re-administration.
ABLAVAR® Injection: As with other contrast media, the possibility of serious or lifethreatening anaphylactic or anaphylactoid reactions, including cardiovascular,
respiratory and/or cutaneous manifestations, should always be considered. As with
other gadolinium based contrast agents, caution should be exercised in patients with
renal insufficiency due to the possibility of further deterioration in renal function.
In clinical trials, a small increase (2.8 msec) in the average change from baseline in QTc
was observed at 45 minutes following ABLAVAR® administration. These QTc
prolongations were not associated with arrhythmias or symptoms. Caution should be
used in patients at high risk for arrhythmias due to baseline QTc prolongation.
Have emergency resuscitative equipment available prior to and during ABLAVAR®
administration.
Please see full Prescribing Information on pages 14-15, including boxed
WARNING regarding Nephrogenic Systemic Fibrosis (NSF).
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2012 Medicare Reimbursement Information Lantheus Medical Imaging
Cardiolite®
(Kit for the Preparation of Technetium Tc 99m Sestamibi for Injection)
Indications and Usage:
Cardiolite®, Kit for the Preparation of Technetium Tc99m Sestamibi for injection, is a
myocardial perfusion agent that is indicated for detecting coronary artery disease by
localizing myocardial ischemia (reversible defects) and infarction (non-reversible
defects), in evaluating myocardial function and developing information for use in patient
management decisions. Cardiolite® evaluation of myocardial ischemia can be
accomplished with rest and cardiovascular stress techniques (e.g., exercise or
pharmacologic stress in accordance with the pharmacologic stress agent’s labeling). It
is usually not possible to determine the age of myocardial infarction or to differentiate a
recent myocardial infarction from ischemia.
Important Safety Information:
Exercise and pharmacologic stress testing should be performed only under the
supervision of a qualified physician. Cardiolite® has been rarely associated with acute
severe allergic and anaphylactic events of angioedema and generalized urticaria. The
most frequently reported adverse events include headache, chest pain/angina, ST
segment changes on ECG, nausea, and abnormal taste and smell.
Please see Full Prescribing Information on pages 16-19.
Medicare 2012 HOPPS values listed in this booklet are based on data from CMS
regulation CMS-1525-FC at:
www.cms.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage.
Overview of Medicare Payment Settings Contrast Agents & Radiopharmaceuticals
Medicare
Hospital
Inpatients
Hospital reimbursement
is based on DRG
payment.
There is no additional
payment for drugs or
imaging procedures.
Medicare
Hospital
Outpatients
Physician Offices
and IDTFs
Imaging procedures paid
separately.
Imaging procedures paid
separately.
Contrast agent & diagnostic
radiopharmaceutical
payments are packaged with
the procedure payment and
not paid separately.
Contrast agents separately
reimbursed based on ASP.
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Radiopharmaceuticals
reimbursed separately based
on AWP or invoice.
2012 Medicare Reimbursement Information Lantheus Medical Imaging
DEFINITY® Vial for (Perflutren Lipid Microsphere) Injectable Suspension
Medicare Hospital Outpatients
For procedures in the hospital outpatient setting Medicare has packaged the payment for
echocardiography contrast agents into the payment for the echocardiography procedure.
Medicare published a list of ten unique “C” codes, one for each echocardiography
procedure to report when contrast echo is performed. Hospitals must report one of these
C codes in order to be reimbursed for the packaged combination of the contrast agent
and the echo procedure.
Hospitals should report the packaged drug HCPCS code in addition to the C code in
®
order for CMS to obtain cost and charge data. DEFINTY should be reported as Q9957
perflutren lipid microsphere, two units per vial. Q9957 will not be paid as a separate line
item, contrast payment is packaged with the appropriate C code.
For Medicare
Hospital
Outpatients
Medicare Payment for Hospital Outpatients
Echocardiography (TTE) with and without contrast
TTE “rest” echo
without contrast
CPT code 933062
Echocardiography transthoracic, real time with image
documentation (2D), includes M-mode recording, when performed,
complete, with spectral Doppler echocardiography and with color
flow Doppler echocardiography.
TTE “rest” echo
with contrast
HCPCS code
C89293
Transthoracic echocardiography with contrast, or without contrast
followed by with contrast, real-time with image documentation (2D)
includes M-Mode recording, when performed complete, with
spectral Doppler echocardiography, and with color flow Doppler
echocardiography
Medicare
Hospital
Outpatient
Payment1
$ 393.18
$ 557.28
Most non Medicare private payers recognize and reimburse for contrast echo studies utilizing
the appropriate C codes. Providers should always confirm the coding, coverage and payment in
their contracts with their payers.
Contrast-enhanced echocardiography procedures can involve:
Supplies such as intravenous infusion sets,
Equipment such as intravenous poles and infusion control devices,
Clinical labor such as nursing or other appropriate personnel involved with
starting an intravenous line and administering contrast agents.
These resources are not required when performing non-contrast echocardiography.
Hospitals should consider these differences when determining charges.
1. www.cms.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage
2. AMA Current Procedural Terminology
3. www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage
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2012 Medicare Reimbursement Information Lantheus Medical Imaging
DEFINITY® Vial for (Perflutren Lipid Microsphere) Injectable Suspension
Medicare Physician Office and IDTF Setting
HCPCS Q9957 Injection, perflutren lipid microspheres, per ml.
Q9957 HCPCS code for DEFINITY®.
DEFINITY® is a single use vial.
When reporting HCPCS Q9957 there are two units per vial of DEFINITY®.
DEFINITY is reimbursed separately by Medicare Part B in the physician office setting.
The payment allowance limits are updated each quarter and listed on the CMS website
at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.
For the 1st quarter of 2012 the Part B Medicare reimbursement was $61.16 per unit, two
units per vial1. This payment amount is updated each quarter.
DEFINITY® is a single use vial. Medicare allows reimbursement for the amount injected
plus the amount discarded when providers use single use vials. Some Part B Medicare
Carriers may require the use of the JW modifier to document the amount of a single use
vial that is discarded2. Check with your local carrier to determine whether they require
use of the JW modifier.
For more reimbursement information go to the ASE website www.asecho.org
Non Medicare private payers usually reimburse echo contrast agents separately in the
physician office and IDTF setting. Providers must check their contracts and / or contact
their private payers to confirm coding, coverage and payment amounts.
1.www.cms.gov/McrPartBDrugAvgSalesPrice/01a18_2012ASPFiles.asp#TopOfPage
2. www.cms.gov/transmittals/downloads/R1478CP.pdf
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2012 Medicare Reimbursement Information Lantheus Medical Imaging
ABLAVAR® gadofosveset trisodium
Medicare Hospital Outpatients
MRA contrast agents are not paid separately by Medicare unless they have pass
through status. Payment for non pass through contrast agents is packaged with the MRA
procedure payment for Medicare hospital outpatients.
Providers should report charges for packaged contrast agents to CMS so that CMS can
obtain the cost and charge data necessary to set future payments.
HCPCS A95831 – gadofosveset trisodium per ml
Medicare Physician Office & Independent Diagnostic Testing Facilities
ABLAVAR® is reimbursed separately by Medicare Part B in the physician office setting.
The payment allowance limits are updated each quarter and listed on the CMS website
at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.
For the 1st quarter of 2012 the Part B Medicare reimbursement was $12.6531 per ml.
Fourth quarter Part B non hospital 2011 payment allowance limit per vial
Payment allowance limit 10 ml vial $126.53
Payment allowance limit 15 ml vial $189.79
This payment allowance limit is updated by CMS each quarter.
HCPCS A9583 Injection, gadofosveset trisodium 1 ml.
ABLAVAR® is a single use vial.
When reporting HCPCS A9583 there are 10 units in a 10 ml single use vial of
ABLAVAR® and 15 units in a 15 ml single use vial.
ABLAVAR® is a single use vial. Medicare allows reimbursement for the amount injected
plus the amount discarded when providers use single use vials. Some Part B Medicare
Carriers may require the use of the JW modifier to document the amount of a single use
vial that is discarded2. Check with your local carrier to determine whether they require
use of the JW modifier.
Non Medicare private payers usually reimburse contrast agents separately in the
physician office and IDTF setting. Providers must check their contracts and / or contact
their private payers to confirm coding, coverage and payment amounts.
1.www.cms.hhs.gov/McrPartBDrugAvgSalesPrice
2. www.cms.gov/transmittals/downloads/R1478CP.pdf
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2012 Medicare Reimbursement Information Lantheus Medical Imaging
2012 Medicare Reimbursement for Nuclear Cardiology
784521- Myocardial perfusion imaging, tomographic (SPECT) (including attenuation
correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated
technique, additional quantification, when performed); multiple studies at rest and / or
stress (exercise or pharmacologic) and / or redistribution and / or rest reinjection.
Medicare Hospital Outpatients Payments
2012 Payment1
78452 - SPECT, wall motion, ejection fraction
includes payment for radiopharmaceutical
$672.28
93017 - Cardiovascular stress test
$178.11
78492 - PET Myocardial Perfusion Imaging,
includes payment for radiopharmaceutical
$1038.06
Medicare Physician Office Setting
Global RVUs
2012
2011
2010
78452 - includes SPECT, wall motion, ejection fraction
78452 - includes SPECT, wall motion, ejection fraction
78452 - includes SPECT, wall motion, ejection fraction
14.792
14.063
12.194
78492 PET myocardial perfusion imaging
Carrier Priced
Cardiolite® A9500 Technetium Tc-99m sestamibi per dose
A9500 Hospital Outpatients - 2012 Medicare radiopharmaceutical payment
packaged with primary procedure.
A9500 Office and IDTF setting - Payment is based on 95% of the AWP, carrier
priced or invoice. Check with your local
contractor for local payment methodology.
1. www.cms.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage
2.www.cms.gov/PhysicianFeeSched/PFSFRN/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=4&sortOrder=descending&itemID=CMS1253669&intNumPerPage=10
3, Federal Register / Vol. 75, No. 228 / Monday, November 29, 2010 p. 73768
4. Federal Register / Vol. 75, No. 226 / Wednesday, November 24, 2010 72437
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2012 Medicare Reimbursement Information Lantheus Medical Imaging
2012 HCPCS Information
Product
HCPCS
Cardiolite®
Kit for the Preparation of
Technetium Tc99m Sestamibi for
Injection
Thallous Chloride Thallium 201
Injection
DEFINITY®
Vial for (Perflutren Lipid
Microsphere) Injectable
Suspension
Gallium Citrate Ga 67 Injection
Neurolite® Kit for the Preparation
of Technetium Tc99m bicisate for
Injection
Xenon Xe 133 Gas
A9500
A9505
Q9957
A9556
A9557
A9558
ABLAVAR® gadofosveset trisodium A9583
Units
Comments
Per Dose
HOPPS payment bundled with primary
procedure. Office setting payment by
invoice or 95% of AWP.
NDC – 11994-0001-00 per dose
Per mCi
HOPPS payment bundled with primary
procedure. Office setting payment by
invoice or 95% of AWP.
NDC – 11994-0427-01 per mCi
Per ml.
Two ml
per vial
HOPPS payment for Q9957 bundled
with primary procedure. Office setting
payment based on Average Selling Price
updated quarterly by CMS.
NDC – 11994-0011-04
Per mCi
HOPPS payment bundled with primary
procedure. Office setting payment by
invoice or 95% of AWP.
NDC – Varies by size
Per Dose
HOPPS payment bundled with primary
procedure. Office setting payment by
invoice or 95% of AWP.
NDC – 11994-0006-00 per dose
Per 10mCi
HOPPS payment bundled with primary
procedure. Office setting payment by
invoice or 95% of AWP.
NDC – Varies by size
Per ml
HOPPS payment bundled with primary
procedure. Reimbursement by ASP
Medicare part B.
NDC 11994-012-01 (10 ml vial)
NDC 11994-012-02 (15 ml vial)
ABLAVAR, Cardiolite, DEFINITY and corporate logo display are registered trademarks of Lantheus Medical Imaging, Inc.
Any unlicensed use of these trademarks is expressly prohibited under the U.S. Trademark Act 275336 v1.
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