As previously reported by ASNC, the Centers for Medicare & Medicaid Services (CMS) finalized bundling payments for seven categories in with the APC payment in the 2008 final Hospital Outpatient Prospective Payment System (HOPPS) rule. All diagnostic radiopharmaceuticals, contrast agents and many imaging add-on codes are now bundled with the cost of the major procedure CPT codes. These services are shown as having status indicator "N," which indicates that the item or service payment is packaged in with another service.

It is important to remember that items and services labeled with status indicator "N" are still considered paid by CMS. The costs of these status "N" services were and will be used by CMS to set the final payment rates and are included in the 2008 and future APC major procedure payments. All coders and billers (charge master managers) should remember to follow HIPAA standards and report all services performed, even those with status indicator "N." For example, a nuclear cardiologist who performs an MPI SPECT, single study with wall motion should include the study procedure code (CPT 78464), as well as the add-on procedure code (CPT 78478), including the radiopharmaceutical HCPCS Level II specific code on the UB04 claim form prior to submitting it to CMS.

Further, in the final rule, CMS stated that they would implement an Outpatient code edit (OCE) that will result in the return of (for correction) any claim for a nuclear medicine procedure that does not contain a HCPCS Level II radiopharmaceutical code.† CMS does not state that any specific radiopharmaceutical be used with a particular procedure, but one must be included on the claim form.

In setting an appropriate charge for radiopharmaceuticals, hospitals should be following the still current CMS guidelines. In Federal Register Vol. 70, No 217, p. 68654, CMS states that they "believe that hospitals can appropriately adjust their charges for radiopharmaceuticals so that the calculated costs properly reflect their actual costs. Specifically, it is appropriate for hospitals to set charges for these agents based on all costs associated with the acquisition, preparation, and handling of these products so that their payments under the OPPS can accurately reflect all of the actual costs associated with providing these products to hospital outpatients."

ASNC cautions hospitals against applying token one cent ($0.01) or one dollar ($1.00) charges simply to get claims paid. CMS will use these claims and charges to set future payments for nuclear cardiology procedures, thus causing risk to future payments should hospitals only apply token charges.