Kit for the Preparation of Technetium Tc 99m
Sulfur Colloid Injection
For Subcutaneous, Intraperitoneal, Intravenous and Oral Use
For Diagnostic Use by Prescription Only

Reimbursement Information Disclaimer

Choose CPT codes for procedures separately ordered, medically necessary and performed following AMA and Specialty Society coding guidelines. Above rates are national and are not wage adjusted.

Be aware of Correct Coding Initiative quarterly updates, Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Procedure coding is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. Coding should be based upon procedures and supplies provided to the patient that accurately describe the medical, surgical, and diagnostic services provided. Coding and reimbursement information is provided to you for educational purposes only and does not assure coverage in a specific case or setting. Neither Pharmalucence nor Merlino Healthcare Consulting, Inc. makes any guarantee of coverage or reimbursement of fees. Contact your commercial plan representative, local Medicare Administrative Contractor or the Centers for Medicare and Medicaid Services (CMS) for specific information as payment rates listed are National and subject to change. To the extent that you submit cost information to Medicare, Medicaid or any other reimbursement program to support claims for services or items, you are obligated to accurately report the actual price paid for such items, including any subsequent adjustments. Current Procedural Terminology numeric codes, descriptions, and modifiers are trademarks and copyrights of the AMA.

See Package Insert for full prescribing Information



Kit for the Preparation of Technetium Tc 99m
Sulfur Colloid Injection
For Subcutaneous, Intraperitoneal, Intravenous and Oral Use
For Diagnostic Use by Prescription Only

Glossary of Reimbursement Terms & Acronyms

Ambulatory Payment Classifications (APC)
APCs are four digit numeric identified categories of procedures composed of services which are similar clinically and with respect to resource utilization and costs. Procedures and their associated CPT or HCPCS codes are assigned to an APC number that in turn corresponds to a specific national payment. Wage adjustments are applied to sixty percent of the APC payment rate. Within this system each APC is also assigned a status indicator (SI) with varying methods of payments such as packaged payments (N) or separately paid payments (S) to name only two.

Average Wholesale Price (AWP)
Redbook and First Databank publish manufacturer supplied pricing information. One of the widely available nationally published data is referred to as an AWP.

Centers for Medicare & Medicaid Services (CMS)
The federal agency that administers the Medicare and Medicaid programs, prior to June 14, 2001 this agency was known as the Healthcare Financing Administration (HCFA).

Current Procedural Terminology (CPT)
CPT is a listing of 5 digit numeric or combinations of alpha and numeric codes with narrative descriptions that are used to report medical services and procedures. Codes are updated annually or biannually and are generally effective January 1 each year, for category III codes twice yearly in January and July. The American Medical Association (AMA) manages these codes; however these codes are generally accepted with the majority of payers across the United States.

Deficit Reduction Act (DRA)
The DRA of 2005 reduces Medicare technical component payments for diagnostic imaging procedures performed under the Medicare physician fee schedule in imaging centers and physician offices. When the hospital technical component is lower than the Physician Fee Schedule payment, Medicare will pay offices and imaging centers the hospital technical payment rate. This is referred to as the DRA CAP or HOPPS (OPPS) CAP, as the payment for the office is capped at the Hospital Outpatient Payment rate.

Healthcare Common Procedural Coding System (HCPCS)
HCPCS Level II is a listing of 4 digit alphanumeric codes with narrative descriptions that are used to report products, supplies, drugs, radiopharmaceuticals, devices and in some cases medical services and procedures not included in the CPT codes such as new technologies. Codes are updated quarterly, January, April, July and October. The CMS manages these codes; however these codes are generally accepted with the majority of payers across the United States.

Hospital Outpatient Prospective Payment System (HOPPS) or (OPPS)
Medicare payment system which utilizes an Ambulatory Patient Classification (APC) grouping system that provides a fixed rate of payments for categories or groupings of hospital services.

Medicare Administrative Contractor (MAC)
The MACs are the contracted claims processing companies who administer the Medicare payment systems by implementing CMS’s national policies on a local state by state basis for Part A and B services. Part A services (institutional aka hospital) were previously administered by Fiscal Intermediaries and the Part B services (non institutional aka physician offices or independent diagnostic imaging centers) were administered by Carriers; these are now merged into a single contractor for consistency and efficiencies.

Physician Fee Schedule (PFS) also referred to as “The Fee Schedule”
Medicare payment system which establishes national and local payments for physicians and independent diagnostic imaging centers (IDTF) based on resource costs associated with three components of these costs; physician work, practice expense and professional liability insurance. Separate geographic adjustments are applied to each of the three components to produce a local payment rate. Imaging procedures paid in this system are broken into three payment components, the professional component (PC) the technical component (TC) or a global payment. The global payment is a combination of the PC added to the TC.

  • The PROFESSIONAL (26) component is billed by the physician in the hospital or non-hospital setting.
  • The TECHNICAL (TC) component is billed for the services of technologists, equipment and the cost of supplies in the hospital or Non-hospital setting.
  • The GLOBAL (no modifier) amount would be billed by the freestanding non-hospital center or physician office and includes both of the above.

Resource Based Relative Value Scale (RBRVS)
A government mandated1 relative value system that is used for calculating national fee schedules for services provided to Medicare patients. Physicians are paid on Relative Value Units (RVUs) for procedures and medical services. The three components of each established value include; physician work RVU, practice expense RVU and malpractice expense RVU. These RVUs are used in the Medicare physician fee schedule as well as used by many other payers as a basis for payment for medical services.


(1) The concepts and methodology underlying the PFS were enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1989 (Pub. L. 101–239), and OBRA 1990, (Pub. L. 101–508).

Kit for the Preparation of Technetium Tc 99m
Sulfur Colloid Injection
For Subcutaneous, Intraperitoneal, Intravenous and Oral Use
For Diagnostic Use by Prescription Only
Reimbursement Information

2016 vs 2017 Final Rule Medicare Reimbursement
(4Q 2016 vs 1Q 2017 Physician Office/IDTF Procedure Allowables)
(4Q 2016 vs 1Q 2017 Hospital Outpatient Procedure Rates)

Radiopharmaceutical
HCPCS Level II Code Descriptor MEDICARE HOSPITAL OUTPATIENT MEDICARE PHYSICIAN OFFICE & INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTF)
SI PAYMENT RATE 2016 vs 2017 TC
2016 vs 2017
PC
2016 vs 2017
GLOBAL
2016 vs 2017
A9541 Technetium tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries N Packaged Payment w/Procedure % of AWP or Invoice Cost Check with Medicare Administrative Contractor

Imaging Procedures
CPT Code Descriptor MEDICARE HOSPITAL OUTPATIENT MEDICARE PHYSICIAN OFFICE & INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTF)
APC PAYMENT RATE TC PC Global
2016 2017 2016 2017 2016 2017 2016 2017 2016 2017
38792 Injection procedure; radioactive tracer for identification of sentinel node 5591 5591 $333 $333 NA NA NA NA $41 $41
78102 Bone marrow imaging; limited area 5591 5591 $333 $333 $150 $151 $27 $27 $177 $179
78103 Bone marrow imagin, multiple areas 5591 5591 $333 $333 $195 $194 $37 $36 $232 $230
78104 Bone marrow imaging; whole body 5591 5591 $333 $333 $217 $218 $39 $39 $256 $257
78195 Lymphatics and lymph nodes imaging 5591 5592 $333 $429 $311 $314 $60 $60 $371 $374
78201 Liver imaging; static only 5591 5593 $333 $1139 $174 $177 $21 $22 $196 $198
78202 Liver imaging; with vascular flow 5591 5593 $333 $1139 $186 $186 $24 $24 $211 $210
78205 Liver imaging (SPECT); 5591 5593 $333 $1139 $186 $187 $34 $34 $221 $221
78215 Liver and spleen imaging; static only 5591 5591 $333 $333 $178 $179 $25 $25 $203 $204
78216 Liver and spleen imaging; with vascular flow 5591 5591 $333 $333 $103 $105 $28 $28 $131 $133
78262 Gastroesophageal reflux study 5591 5591 $333 $333 $221 $221 $34 $34 $255 $254
78264 Gastric emptying study 5591 5591 $333 $333 $312 $313 $37 $40 $349 $353
78291 Paritoneal-venous shunt patency test (eg. for LeVeen, Denver shunt) 5591 5591 $333 $333 $220 $225 $43 $44 $263 $268
78800 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area 5591 5591 $333 $333 $165 $168 $34 $34 $199 $202
78803 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) 5592 5592 $707 $441 $302 $305 $53 $53 $355 $359


Sentinel Node Imaging Using Technetium Tc 99m Sulfur Colloid Injection

To identify the Medicare Physician payment rate for your specific geographical region, visit the CMS website at:
cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html

Click here for more information for Medicare HOPPS Reference or paste this link in your browser: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1633-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

Click here for more information for Medicare PFS References or paste link in your browser: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1631-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

For calculation of 4Q 2016 rates in the above Table, the conversion factor $35.8043 was used.

For calculation of 1Q 2017 rates in the above Table, the conversion factor $35.8887 was used.

For more information including reimbursement guidance, please see the Society of Nuclear Medicine and Molecular Imaging (SNMMI) Practice Management Coding Corner Q & A “Coding Sentinel Node Injection With and Without Imaging.”

For additional reference several SNMMI Practice Guidelines describing the use of Technetium Tc 99m sulfur colloid imaging for Gastric Emptying, Small-Bowel and Colon Transit, Liver and Spleen, Hepatic and Splenic, Cystography, Cystography in Children, Lymphatic or Sentinel Node for Breast Cancer or for Melanoma, can be found in the Quality and Practice section under Guidance followed by Guidelines of the SNMMI website.


Sulfur Colloid Injection
Kit for the Preparation of Technetium Tc 99m

Choose CPT codes for procedures separately ordered, medically necessary and performed following AMA and Specialty Society coding guidelines. Above rates are national and are not wage adjusted.

Be aware of Correct Coding Initiative quarterly updates, Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Procedure coding is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. Coding should be based upon procedures and supplies provided to the patient that accurately describe the medical, surgical, and diagnostic services provided. Coding and reimbursement information is provided to you for educational purposes only and does not assure coverage in a specific case or setting. Neither Pharmalucence nor Merlino Healthcare Consulting, Inc. makes any guarantee of coverage or reimbursement of fees. Contact your commercial plan representative, local Medicare Administrative Contractor or the Centers for Medicare and Medicaid Services (CMS) for specific information as payment rates listed are National and subject to change. To the extent that you submit cost information to Medicare, Medicaid or any other reimbursement program to support claims for services or items, you are obligated to accurately report the actual price paid for such items, including any subsequent adjustments. Current Procedural Terminology numeric codes, descriptions, and modifiers are trademarks and copyrights of the AMA.

See Package Insert for full prescribing Information.