Heidi, when you say "charge" I typically interpret this to mean your full billed, however, based upon the nature of your question is sounds like you are talking more about how you are paid.
I also tend to think of contrast materials (LOCM, Dotarem) in the same bucket of radiopharmaceuticals (whether contrast is "technically" a radiopharmaceutical is a different discussion).
Having said that, Medicare will typically pay on invoice with exceptions, LOCM and Dotarem are the notable ones. Commercial carriers will be contract dependent.
Drugs (as I generically call all of the above) are always an interesting endeavor in evaluating payments/contract compliance, are you covering your cost etc. Then lump in sequestration and you are already behind for Medicare.
During our review of A9587 we found a rather peculiar anomaly with the code descriptor, how we were billing (i.e. units), the MUEs for this code and how other payors were reimbursing this code. Guess it shouldn't surprise me that there are exceptions to just about every rule.
Interesting background on this code below.
https://www.cms.gov/medicare/coding/medhcpcsgeninfo/downloads/2018-05-16-hcpcs-application-summary.pdf
You really have to pull EOBs, look at allowed amounts per unit, compare to your contract language and go from there.
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Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
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Original Message:
Sent: 11-27-2024 12:51
From: Heidi Simpson
Subject: Reimbursement for radiopharmaceutical codes
Hello!
A question has come up in our practice as to what to charge for radiopharmaceuticals. We know that for CMS that its the invoice cost. Is that also the case for all commercial insurances? We are a private imaging center located in Maryland.
Thanks,
Heidi Simpson
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Heidi Simpson RT (R) (N) CNMT
Operations Manager
Advanced Diagnostic Radiology LLC
Cumberland, MD
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