Xofigo® (radium Ra 223 dichloride)

Question:
Could you please tell us how to code the FDA approved (May 15, 2013) therapeutic injection procedure and radiopharmaceutical Xofigo®? This is for the treatment of our patients with castration-resistant prostate cancer (CRPC), symptomatic bone metastases and no known visceral metastatic disease.

Answer:

For dates of service January 1, 2015 and beyond, CMS has established a permanent HCPCS code that should be use in both the HOPPS and MPFS settings unless payers dictate otherwise. The new on January 1, 2015 HCPCS level II code and description is A9606 Radium ra-223 dichloride, therapeutic, per microcurie. SNMMI is disappointed that this description is not per treatment dose as requested.

The SNMMI recommends the use of the JW modifier to report wasted product and for providers to report the full costs of the ordered dose, along with the patient administered dose. When reporting any HCPCS code, providers must report the number of units per the HCPCS description that are administered to the patient and not the ordered dose. However, the SNMMI recommends reporting any wasted product from ordered dose to administer dose by reporting those units with the HCPCS description followed by the JW modifier. This modifier will identify to the payer that you had product at a cost to the provider that was not administered to the patient and was discarded or wasted. The use of the JW modifier is an important mechanism for providers to be able to report the costs and be paid appropriately for radiopharmaceuticals. More information regarding JW modifiers can be located on a CMS Q&A located at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

Regarding coding for the therapeutic injection procedure, SNMMI recommends CPT code 79101 Radiopharmaceutical therapy, by intravenous administration for all settings and payers.

Note: Independent diagnostic testing facilities (IDTF) would not perform therapeutic services. CMS states, “An IDTF shall not be allowed to bill for any CPT or HCPCS codes that are solely therapeutic.”

The opinions referenced are those of the members of the SNMMI Coding and Reimbursement Committee and their consultants based on their coding experience. They are based on the commonly used codes in Nuclear Medicine, which are not all inclusive. Always check with your local insurance carriers as policies vary by region. The final decision for the coding of a procedure must be made by the physician considering regulations of insurance carriers and any local, state or federal laws that apply to the physicians practice. The SNMMI and its representatives disclaim any liability arising from the use of these opinions.