Drugs and Biologicals

Radiopharmaceutical Reimbursement

National Government Services has reviewed the radiopharmaceutical pricing methodology set forth in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Section 303(h) which states that for dates of service on or after 1/1/2005 radiopharmaceutical payment allowance limits are not subject to ASP. Contractors are to determine radiopharmaceutical payment allowance limits based on the methodology in place as of November 2003.

Claim Submission Guidelines

Claims submitted for radiopharmaceuticals (HCPCS codes A9500–A9700) that are not priced by CMS or NGS must include either invoice information or a copy of the actual invoice for pricing purposes.

For electronic claims, report the invoice information in the electronic Documentation Field (Loop 2300, NTE Segment [header level] or Loop 2400, NTE Segment [line level]).

The name of the radiopharmaceutical and the exact dosage administered must appear in the Documentation Field.

  • If the charge matches the actual invoice cost, note "Actual Invoice Cost" in the Documentation Field.
  • If you are submitting a charge greater than the actual invoice cost, please include the following information in the Documentation Field, using these abbreviations:
    • Des = Description/Name of agent (e.g., Des=TC99m MDP)
    • QS = Quantity shipped (e.g., QS=100 mci)
    • TA = Total amount charged for quantity shipped (e.g., TA=$57.40)
    • UP = Unit Price (e.g., UP = $0.57 per mci) (Optional)
    • DG = Dosage given (e.g., DG=25 mci)

Services Rendered on or after 1/1/2024

Code Narrative Allowance Invoice Required Contractor-Priced CMS-Priced
A9500 Tc99-m sestamibi Cardiolite $127.05   X  
A9502 Tc99-m sestamibi, tetrafosmin Myoview .23 mg $779.69

1.38 mg $2777.61		   X  
A9503 Tc99-m medronate $93.31   X  
A9513 Lutetium 177, dictate, Lutathera

1/1/2024-
1/9/2024
$312.36

1/10/2024-
12/31/2024
$318.61

   X  
A9524 Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries, Volumex 1/1/2024-
1/31/2024
$118.09

2/1/2024-
6/31/2024
$141.09

No claims for this so not priced for 7/1/2024-
9/30/2024		   X  
A9541 Tc99m sulfur colloid $142.77   X  
A9547 Indium IN-111 oxyquinoline, per 0.5 mci 1/1/2024-
6/30/2024 $2399.68
*Updated 4/1/2024 from $2221.92

No claims for this so not priced for 7/1/2024-
9/30/2024		   X  
A9548 Indium IN-111 pentetate, per 0.5 mci 1/1/2024-
9/30/2024 $961.40		   X  
A9552** Fluorodeooxyglucose F-18 FDG $527.67   X  
A9555 Rubidium Rb-82 $532.65   X  
A9558 Xenon Xe-133 gas, per 10 mci $276.97   X  
A9573 Vueway (gadopiclenol), per ml 1/1/2024-3/31/2024 $12.78   X X
Effective 4/1/2024 has ASP pricing

 
A9575* gadoterate meglumine Refer to fee schedule     X
A9576* gadoteridol (prohance multipack) Refer to fee schedule     X
A9577* gadobenate dimeglumin (multihance) Refer to fee schedule     X
A9578* gadovenate (multihance multipack) Refer to fee schedule     X
A9579* Gadolinium-based magnetic resonance contrast agent Refer to fee schedule     X
A9581* gadoxetate disodiumj Refer to fee schedule     X
A9585* Gadobutrol Refer to fee schedule     X
A9588 Fluciclovine f-18   X    
A9591 Cerianna fluoroestradiol F 18 per millicurie   X    
A9592 Copper Cu 64 Dotatate, per millicurie $1097.25   X  
A9595 Piflufolastat f-18, diagnostic (Pylarify) $661.54   X  
A9596 Illuccix® (Gallium 68-ga Gozetotide/PSMA-11) per millicurie $1121.76 per mci   X  
A9606* Xofigo radium ra-223 dichloride, per mci $181.62 X    
A9607 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) 1/1/2024-
12/31/2024
$271.13		   X  
A9608 Flotufolastat F18 (Posluma) $700.85   X  
A9800 LOCAMETZ™ (kit for preparation of Gallium 68-ga Gozetotide/PSMA-11)   X    

 

Services Rendered 1/1/2023–12/31/2023

Code Narrative Allowance Invoice Required Contractor-Priced CMS-Priced
A4641 Posluma Flotufolastat F18 per mci $716.25 for 5/25/23–
12/31/23		   X  
A9500 Tc99-m sestamibi Cardiolite $123.35   X  
A9502 Tc99-m sestamibi, tetrafosmin Myoview .23 mg $779.69

1.38 mg $2777.61		   X  
A9503 Tc99-m medronate $93.31   X  
A9513 Lutetium 177, dictate, Lutathera   X    
A9524 Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries $118.09   X  
A9541 Tc99m sulfur colloid $142.77   X  
A9552** Fluorodeooxyglucose F-18 FDG $527.67   X  
A9555 Rubidium Rb-82 $532.65   X  
A9575* gadoterate meglumine Refer to fee schedule     X
A9576* gadoteridol ( prohance multipack) Refer to fee schedule     X
A9577* gadobenate dimeglumin (multihance) Refer to fee schedule     X
A9578* gadovenate (multihance multipack) Refer to fee schedule     X
A9579* Gadolinium-based magnetic resonance contrast agent Refer to fee schedule     X
A9581* gadoxetate disodiumj Refer to fee schedule     X
A9585* Gadobutrol Refer to fee schedule     X
A9588 Fluciclovine f-18   X    
A9591 Cerianna fluoroestradiol F 18   X    
A9595 Piflufolastat f-18, diagnostic (Pylarify) $624.15   X  
A9596 Illuccix® (Gallium 68-ga Gozetotide/PSMA-11) $1071.60 per mci      
A9606* Xofigo radium ra-223 dichloride Refer to fee schedule     X
A9607 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) 1/4/2023: $242.25, eff 3/1/23 $247.10      
A9800 LOCAMETZ™ (kit for preparation of Gallium 68-ga Gozetotide/PSMA-11)   X    


* CMS has established pricing information for these radiopharmaceuticals and they can be found under Medicare Part B Drug Average Sales Price pricing files when posted by CMS.

** The fee for Fluorodeooxyglucose (F-18 FDG) reflects an amount that has been recalculated for all regions. The fee represents an increase for some regions and a decrease in other regions.

Fees may be updated on a quarterly or annual basis.

Revised 10/28/2024