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- |
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