The reimbursement for CEA-Scan will be dependent on the setting in which it is administered and the payer being billed. The information below outlines the likely reimbursement environment in a Medicare setting.

Medicare Payer

Hospital Inpatient

• Part of DRG

Hospital Outpatient

• Bill separately with CPT/HCPCS code and revenue code as discussed in the Description of Forms and Codes section.
• Reimbursement is based on reasonable cost and is no longer subject to the Radiology payment limit.
• The reasonable cost reimbursement is in relation to your facility's current cost to charge ratio.

Freestanding Facility & Physician Office

• Bill separately with CPT/HCPCS code as discussed in the Description of Forms and Codes section.
• Reimbursement can be based on the lower of the actual charge (invoice cost), the average wholesale price (AWP), or in the case of multiple source drugs, the median of all of the AWPs, or an estimate of actual acquisition cost.
• Some payers want a paper claim submitted with an invoice attached.
• Other payers will allow electronic claim submission.
• Invoice copy should be kept on file.

Private Payers

The reimbursement policies of commercial insurers can vary. Separate payment for the radiopharmaceuticals also varies. Many of these insurers feel that the radiopharmaceuticals and any other supplies used in the imaging procedure are part of the procedure; therefore, they will not reimburse providers separately.

HCFA 1500 - Represents the standard billing mechanism for physicians and freestanding outpatient centers. CPT/HCPCS and ICD-9-CM codes should be included on this form. Physicians and freestanding clinics should bill separately for the radiopharmaceuticals using the appropriate CPT/HCPCS code.

UNIVERSAL BILLING FORM - UB92 - Represents the standard billing form for hospital outpatient or inpatient claims. CPT/HCPCS codes, revenue codes and ICD-9-CM codes should be included on this form. Hospitals should bill separately for the radiopharmaceuticals using the appropriate CPT/HCPCS code and revenue code.

GLOBAL  BILLING - If the procedure is performed in the physician's office using privately owned equipment, the provider can bill for the technical component as well as the professional component (the fee amount for the physician's supervision and interpretation).

Freestanding clinics who own their equipment can also bill for the technical and professional components of an imaging procedure.

TECHNICAL COMPONENT - Hospitals can bill for the "technical component" portion of the imaging procedure which means that they can only receive reimbursement for the provision of facilities and for the technician's time.

PROFESSIONAL COMPONENT - A charge may be made for the physician component (supervision and interpretation) alone. Under those circumstances, a modifier "26" is added to the CPT procedure code.

CPT/HCPCS CODES - Describe medical services and procedures. They are used by physicians, freestanding facilities and hospital outpatient centers in billing. The following CPT codes may be applicable to use when billing CEA-Scan and its administration.

78800      Radiopharmaceutical Localization of tumor- Limited Area
78801      Radiopharmaceutical Localization of tumor- Multiple Area
78802      Radiopharmaceutical Localization of tumor- Whole Body
78803      Tumor localization (SPECT)

CEA-Scan

^Medicare

^{C1122    Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified. List the name CEA-Scan and the dosage used on the claim form. If filing a paper claim, attach the invoice.}

^{Private Payers}

Many commercial insurers are still requesting the following National Level I CPT code for the diagnostic radiopharmaceutical identification.

^{78990    Provision of diagnostic radiopharmaceutical(s)}

^{REVENUE CODES FOR HOSPITAL CLAIM SUBMISSIONS - All CPT codes for hospital outpatient claims must be linked to a particular revenue code for accounting purposes and are required for reimbursement. Listed below are the revenue codes that are most appropriate to bill for the procedure, CEA-Scan, and other related items.}

^{258   I.V. Solution}
340   Nuclear Medicine, general
341   Nuclear medicine, diagnostic
621   Supplies incident to Radiology
636   Drugs that require detailed coding

* Revenue Code Changes for Hospital Outpatient Medicare Claims (May, 1996)

The Health Care Financing Administration (HCFA) issued Medicare Intermediary Manual Transmittal #1681 (section 3631) and Hospital Manual Transmittal #693 (section 443), both of which state that for reporting radiopharmaceuticals, revenue codes 250, 32x, 35x and 61x are no longer listed. These transmittals state that providers should use 34x or 636.

The revenue codes a Medicare Fiscal Intermediary will accept can vary geographically. Nuclear Medicine department personnel should discuss this with the hospital business office to determine which revenue code their Medicare Fiscal intermediary will accept.

GLOBAL  BILLING - If the procedure is performed in the physician's office using privately owned equipment, the provider can bill for the technical component (facility costs, nursing and supplies) as well as the professional component (the fee amount for the physician's supervision and interpretation).

Freestanding clinics who own their equipment can also bill for the technical and professional components of an imaging procedure.

TECHNICAL COMPONENT - Hospitals can bill for the "technical component" portion of the imaging procedure which means that they can only receive reimbursement for the provision of facilities and for the technician's time.

PROFESSIONAL COMPONENT - A charge may be made for the physician component (supervision and interpretation) alone. Under those circumstances, a modifier "26" is added to the CPT procedure code.

The tables below detail the appropriate forms and codes that may be used when billing for CEA-Scan and its administration

ICD - 9 - CM DIAGNOSIS CODES - International Classification of Disease (ICD) codes describe the patient's condition or diagnosis and provide the medical necessity for the procedure(s) performed. they are required on all claim forms. Choose the appropriate three, four or five digit ICD-9 code to justify why a particular nuclear medicine diagnostic test was administered to the patient. Be as specific as possible by using Volumes 1 and 2 of the ICD-9-CM if needed.

For a complete listing of diagnosis codes applicable to CEA-Scan, see below.

153.x Malignant neoplasm of colon

153.0  Hepatic flexure

153.1  Transverse colon

153.2  Descending colon, left colon

153.3  Sigmoid colon, sigmoid flexure

153.4  Cecum, ileocecal valve

153.5  Appendix

153.6  Ascending colon, right colon

153.7  Splenic flexure

153.8  Other sites of large intestine whose point of origin can not be determined

153.9  Unspecified large intestine NOS

154.x Malignant neoplasm of rectum rectosigmoid junction, and anus

154.0  Rectosigmoid junction, colon with rectum

154.1  Rectum

154.2  Anal canal and sphincter

154.8  Other sites whose point of origin can not be determined