Medicare Announces add-on payment for non-HEU sourced Tc-99m based radiopharmaceuticals in the 2013 Hospital Outpatient Prospective Payment System (HOPPS) Final Rule 

NOTE: The changes in the final rule go into effect January 1, 2013. 

CMS has finalized the add-on payment policy for non-HEU sourced Tc-99m based radiopharmaceuticals. For Tc-99m based radiopharmaceuticals which are derived from at least 95% non-HEU sources and priced through the Full Cost Recovery method, CMS has established a new HCPCS code Q9969 (Tc-99m from non highly enriched uranium source, full cost recovery add-on, per study dose) for calendar year 2013. HCPCS code Q9969 is assigned to APC 1442 (Non-HEU Tc-99m Add-On/Dose) with a status indicator of “K” and a CY 2013 payment rate of $10. 

When billing HCPCS code Q9969, hospitals should use a token charge of $1 and will be paid $10. Hospitals should also maintain records which certify that the dose was 95% non-HEU derived.₁

The intent of the add-on code and payment is to ensure equitable payments to hospitals through the transition to more expensive non-HEU sources while they are not uniformly distributed. In other words, the limited supply of non-HEU Tc-99m based radiopharmaceuticals (estimated at 10 – 15% in 2013) will not be available to all hospitals. The cost of these radiopharmaceuticals will be higher due to decreased efficiencies and the use of new unsubsidized sources (reactors), CMS wanted to ensure that the hospitals that use non-HEU Tc-99m based radiopharmaceuticals will recover the additional cost of these doses. ₁

1. Pages 373 – 376; CMS-1589-FC; Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Electronic Reporting Pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; Revision to Quality Improvement Organization Regulations

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Reimbursement information is provided by Cardinal Health as general coding and payment information. This information is not intended to replace or serve as substitute for your duty to verify that such information is proper for your particular circumstances. Any codes reported should accurately reflect the procedures performed and the patient’s conditions. You may want to consult with local payers to confirm compliance with local policies, or otherwise review and confirm reimbursement policies with your own legal or other professional advisors.