Medicare Administrative Contractors publish radiopharmaceutical fee schedule amounts to establish payment limits for specific HCPCS codes. These amounts are not intended to represent guaranteed payment, nor are they intended to override the requirement that claims accurately reflect the provider's actual acquisition cost when applicable.

Visit our website to view the Noridian radiopharmaceutical fee schedule.

Recent questions related to HCPCS code A9555 (Rubidium rb-82, diagnostic, per study dose, up to 60 millicuries) have highlighted the need for additional clarification regarding how radiopharmaceutical payment limits should be interpreted and how providers are expected to bill for these items. This clarification applies broadly to radiopharmaceuticals and is not limited to A9555.

Radiopharmaceutical Fee Schedule Amounts Represent Payment Limits

Radiopharmaceutical fee schedule amounts published by the MAC represent the maximum allowable payment for the base unit of the code for the drug or tracer reported on the claim. These amounts are established under Medicare Claims Processing Manual authority, which directs A/B MACs (B) to determine payment limits for radiopharmaceuticals using pricing methodologies that were in place prior to November 2003, such as invoice‑based pricing or other historically established approaches.

Importantly, the amount listed on the fee schedule should not be interpreted as a flat or guaranteed payment irrespective of cost. Instead, it functions as a ceiling for the payment unit.

Providers Are Expected to Bill Their Actual Cost

When billing for radiopharmaceuticals, providers are expected to submit charges that accurately reflect their actual acquisition cost, consistent with applicable billing and documentation requirements. If the provider's actual cost is less than the published payment limit, Medicare payment is generally made at the lower of:

• the billed (actual) cost, or
• the established payment limit.

This principle applies even when a fixed rate, per‑dose, or per study amount is shown on the fee schedule. The presence of a listed amount does not eliminate the expectation that the claim reflects the true cost incurred by the provider.

Key Takeaway for Providers

Radiopharmaceutical fee schedule amounts are payment limits, not standard payments. Providers should continue to:

• bill radiopharmaceuticals based on their actual acquisition cost, and
• understand that Medicare reimbursement will not exceed the published payment limit and may be less if the billed cost is lower.

Providers with questions about appropriate billing or documentation for specific radiopharmaceuticals are encouraged to contact their Medicare Administrative Contractor for additional guidance.