The coding for a new FDA-approved diagnostic radiopharmaceutical evolves as with any new drug or new therapeutic radiopharmaceutical. We expect this evolution to occur over the next year or two and we encourage SNMMI members to check SNMMI's website regularly for updates. We also call to your attention that the various codes and reimbursement rates will change based on the billing setting and date of service during the evolution and implementation of a new drug and service. It is important to pay attention to the setting; Medicare hospital outpatient, Medicare physician fee schedule, independent diagnostic testing facilities (IDTF), or third-party payers (TPP) and the date of service (DOS) of the procedure for appropriate billing instructions.
Regarding the Diagnostic Radiopharmaceutical coding, for DOS immediate post-FDA approval (beginning on or after September 24, 2024 to March 31, 2025), hospital outpatient departments IDTFs, physician offices, and TPPs use HCPCS Level II code A9598 Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified, per study dose. When requested by any payer or when using any one of the not otherwise classified HCPCS level II codes you may need to include the NDC on the claim form so that the payer can identify the drug and manufacturer more easily. GE has supplied us with the NCD number 0407-8787-01. Some payers may request J3490 Unclassified drugs which is another unlisted drug code, so do check with the local payer to report the correct temporary billing HCPCS code.
For DOS April 1, 2025 and after and for all the payer types use the HCPCS Level II code A9611 Flurpiridaz f 18, diagnostic, 1 millicurie. Medicare encourages physicians to schedule patients in such a way that they can use drugs or radiopharmaceuticals most efficiently. However, if a physician must discard the remainder of a single use vial, the Medicare program covers the amount of drug or radiopharmaceutical discarded/decayed/wasted along with the amount administered. Effective July 1, 2023, providers of separately paid drugs or radiopharmaceuticals from single use administrations are now required to report the waste with the JW modifier or if there is no waste to report the JZ modifier. This is important for CMS tracking and for consistency across the Medicare Administrative Contractors (MACs). More information on the use of JW and JZ modifiers can be found on the SNMMI website at https://sites.snmmi.org/Web/Clinical-Practice/Coding-and-Reimbursement/Web/Clinical-Practice/Coding-and-Reimbursement/QAs/Billing-Discarded-Wasted%20Drugs-Adenosine-or-Radiopharmaceuticals-JW-JZ-Modifiers.aspx
Regarding coding for the PET myocardial perfusion procedures with this new diagnostic tracer use the single best CPT® code based on the procedure performed, this could include CPT® codes; 78491 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), 78492 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), 78430 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan, 78431 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan, 78432 Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability);, or 78433 Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan. When performed, and if the study is separately ordered and medically necessary, providers may also consider +78434 Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) (Use 78434 in conjunction with 78431, 78492) CPT® copyright 2025 American Medical Association. All rights reserved.