Trailblazer Updates Systems and Further Clarifies Radiopharmaceutical Guidance

September 21, 2010

Trailblazer Updates Systems and Further Clarifies Radiopharmaceutical Guidance

SNM and TrailBlazer Health continue their collaborations by sharing important information for our members regarding myocardial perfusion imaging (MPI) agents and appropriate coding, billing and payments for radiopharmaceuticals. As we told you on July 19, 2010, TrailBlazer Health posted additional clarifying radiopharmaceutical guidance for documentation and billing for all radiopharmaceuticals. Most importantly, TrailBlazer has agree to drop the limit of one (1) unit per day and allow, when appropriate, up to two (2) units of A9500 (Technetium, Tc-99m sestamibi, diagnostic, per study dose) and A9502 (Technetium, Tc-99m tetrofosmin, diagnostic, per study dose), following medical society coding guidance. The policy does not specify the limit has been dropped rather it focuses on the appropriate documentation and policy for coding and billing.

SNM has received confirmation that this policy of allowing up to two (2) units when two study doses are purchased and administered is extended to A9526 (Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries) and A9555 (Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries) as these are also appropriate MPI agents working much the same as A9500 and A9502. The Cardiac MPI radiopharmaceuticals claims edit is implemented beginning September 17, 2010, however it is retroactive to January 1, 2010.

One important note regarding claims processing that TrailBlazer has shared with SNM for handling any retroactive claims that were paid under the old policy: providers will need to file an appeal to be reimbursed for those second doses for those retroactive claims. Providers should NOT resubmit claims, as those claims would be viewed in their systems as duplicate and will not be reimbursed.