A9516 I-123 Sodium Iodide HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS A9516: Iodine I-123 Sodium Iodide, Diagnostic Per 100 Microcuries

HCPCS Level II code A9516 denotes Iodine I-123 sodium iodide for diagnostic use, billed per 100 microcuries (up to 999 microcuries). This radiopharmaceutical is used primarily in nuclear medicine to evaluate thyroid function and to localize thyroid tissue, making it an important diagnostic supply in endocrinology and oncology imaging. Nationally, accurate coding for radiopharmaceuticals like A9516 affects billing clarity, supply tracking, and payment consistency across payers.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for A9516, typical sites of service, and which national payers commonly reimburse or manage claims for radiopharmaceutical supplies. The publication provides benchmarks where available, summarizes relevant policy and coverage considerations, and outlines billing nuances related to unit reporting and dose increments.

This summary serves clinicians, billing professionals, and policy analysts seeking a clear, national-level reference for the use and billing of HCPCS Level II code A9516. Data not available in the input are clearly noted in the body of the report.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareA9516HCPCS Level IIradiopharmaceuticalnuclear medicinethyroid imagingI-123 sodium iodidediagnostic imagingradiology billing

Billing Code Overview

HCPCS Level II code A9516 describes Iodine I-123 sodium iodide for diagnostic use, billed per 100 microcuries with dosing reported up to 999 microcuries. This item represents a radiopharmaceutical supplied for nuclear medicine diagnostic studies that require administration of I-123 sodium iodide to evaluate thyroid function or locate thyroid tissue.

Service type: Diagnostic radiopharmaceutical administration for nuclear medicine imaging
Typical site of service: Nuclear medicine departments, hospital outpatient imaging centers, and freestanding imaging facilities that perform diagnostic thyroid scans and related procedures

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult referred from endocrinology for diagnostic thyroid imaging and uptake measurement using radiolabeled iodine-123 sodium iodide. The patient presents with symptoms such as a new thyroid nodule(s), unexplained thyrotoxicosis, or discrepant thyroid function tests after antithyroid therapy. The clinical workflow: the patient undergoes pre-authorization and screening for pregnancy; medication instructions (e.g., withholding interfering iodine-containing medications and certain thyroid medications) are provided. On the day of service at an outpatient nuclear medicine department or hospital radiology/nuclear medicine suite, a technologist administers a measured diagnostic dose of I-123 sodium iodide per 100 microcuries as billed under A9516 (up to 999 microcuries). Serial imaging and thyroid uptake measurements are obtained at protocol-specified times (for example 4–6 hours and 24 hours) using a gamma camera. A nuclear medicine physician interprets the images and quantitative uptake values, generates a report, and communicates findings to the referring clinician. Specimen collection is not required. Typical sites of service: outpatient hospital radiology/nuclear medicine department, freestanding imaging center, or an academic medical center. Typical patient scenario: a 45-year-old woman with new onset palpitations, suppressed TSH, elevated free T4, and a palpable 1.5 cm thyroid nodule undergoes thyroid scintigraphy with I-123 to differentiate Graves disease, toxic multinodular goiter, or a toxic adenoma and to evaluate nodule function before potential biopsy or surgery.

Coding Specifications

HCPCS A9604: Samarium sm-153 Lexidronam Therapeutic Dose

HCPCS-A9577-GADOBENATE-DIMEGLUMINE-CONTRAST-PER-ML

HCPCS A9577: Gadobenate Dimeglumine (Multihance) Injection, per mL

HCPCS-A9530-IODINE-I-131-THERAPEUTIC-SOLUTION-PER-MILLICURIE

HCPCS A9530: Iodine I-131 Sodium Iodide Solution, Therapeutic

HCPCS-A9281-REACHING-GRABBING-DEVICE-ASSISTIVE-REACHER

HCPCS A9281: Reaching/Grabbing Device, Assistive Reacher

HCPCS-A9501-TECHNETIUM-TC-99M-TEBOROXIME-DIAGNOSTIC-STUDY-DOSE

HCPCS Level II A9501: Technetium tc-99m teboroxime Diagnostic Study Dose

HCPCS-A9560-TECHNETIUM-TC-99M-LABELED-RBC-DIAGNOSTIC-UP-TO-30-MCI

HCPCS A9560: Technetium Tc-99m Labeled Red Blood Cells, Diagnostic

HCPCS-A9595-PIFLUFOLASTAT-F18-PET-RADIOTRACER-1-MILLICURIE

HCPCS A9595: Piflufolastat F-18, Diagnostic Radiopharmaceutical, 1 mCi

HCPCS-A9616-GALLIUM-GA-68-GOZETOTIDE-DIAGNOSTIC-PET-TRACER-1-MILLICURIE

HCPCS A9616: Gallium Ga-68 Gozetotide, Diagnostic, 1 Millicurie

HCPCS-A9279-MONITORING-DEVICE-STAND-ALONE-OR-INTEGRATED

HCPCS A9279: Monitoring Feature or Device, Stand‑Alone or Integrated

HCPCS-A9608-FLOTUFOLASTAT-F18-DIAGNOSTIC-1-MILLICURIE

HCPCS A9608: Flotufolastat F 18 Diagnostic, 1 Millicurie

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`22`	Increased procedural services	Use when work or resources substantially exceed the usual for diagnostic radiopharmaceutical administration due to complex patient management or extended time.
`23`	Unusual anesthesia	Use if unrelated to the radiopharmaceutical a separate unusual anesthesia service is provided (rare for this procedure).
`52`	Reduced services	Use when the full diagnostic study is partially reduced or not completed.
`53`	Discontinued procedure	Use if the procedure is started but terminated due to patient instability or other unforeseen circumstances.
`59`	Distinct procedural service	Use when another separately identifiable procedure or service is performed on the same day and is not usually reported with `A9516`.
`62`	Two surgeons	Use only when two surgeons are required for a related invasive procedure (rarely applicable to diagnostic radiopharmaceuticals).
`78`	Return to OR for related procedure	Not commonly used with `A9516` but applies if a subsequent related operative procedure occurs during the global period.
`80`	Assistant surgeon	Use when an assistant surgeon is documented for an associated operative procedure.
`82`	Assistant surgeon (when qualified resident unavailable)	As above, for associated surgery when no resident is available.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for Medicare	Use when a qualified non-physician practitioner provided an identifiable part of the service under Medicare rules.
`GZ`	Service expected to be denied as not reasonable and necessary	Use when no documentation of medical necessity is available and the provider anticipates denial.
`GA`	Waiver of liability statement on file (ABN)	Use when Advance Beneficiary Notice is on file and payer requires the modifier to indicate patient liability.
`XE`	Separate encounter, a service that is distinct because it occurred during a separate encounter	Use when the radiopharmaceutical administration is on a separate date of service than another procedure billed same-day.
`XU`	Unusual non-overlapping service	Use when the radiopharmaceutical administration is distinct and separate from other services on the same day.

Taxonomy Code	Specialty	Notes
`2084P0800X`	Nuclear Medicine Physician	Interprets scintigraphy and quantitative uptake studies.
`207RC0000X`	Radiologist — Diagnostic Radiology	May supervise and interpret nuclear medicine studies in some settings.
`363L00000X`	Nuclear Medicine Technologist	Performs radiopharmaceutical preparation, administration, and imaging acquisition.
`2085R0200X`	Endocrinology	Refers patients for diagnostic thyroid scanning and manages follow-up care.
`2086S0105X`	Otolaryngology (ENT)	May refer for localization studies prior to surgical planning.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E05.00`	Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm	Common indication for thyroid uptake and scan to differentiate Graves disease from other causes.
`E05.90`	Thyrotoxicosis, unspecified without thyrotoxic crisis or storm	Used when hyperthyroidism is present but specific cause is undetermined; scintigraphy helps identify etiology.
`E04.1`	Nontoxic single thyroid nodule	Scintigraphy determines whether the nodule is functioning (hot) or nonfunctioning (cold), guiding management.
`E04.2`	Nontoxic multinodular goiter	Imaging helps localize hyperfunctioning nodules and assess overall gland activity.
`R22.1`	Localized swelling, mass and lump, neck	Symptom code associated with palpable thyroid nodules prompting scintigraphic evaluation.
`E01.1`	Iodine-deficiency related goiter	May prompt functional imaging to assess gland activity in regions or patients with suspected iodine deficiency.
`C73`	Malignant neoplasm of thyroid gland	Although scintigraphy is not diagnostic for cancer, it helps identify nonfunctioning nodules that may require biopsy for malignant evaluation.
`E01.0`	Congenital iodine-deficiency syndrome, neurological type	Rare pediatric indication where thyroid imaging and uptake may be part of developmental/metabolic assessment.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`78012`	Thyroid imaging, planar; static (scintigraphy)	Planar thyroid scintigraphy often performed after `I-123` administration to evaluate nodule function and gland morphology.
`78013`	Thyroid imaging, planar; with quantitative uptake measurement	Used when quantitative thyroid uptake values are calculated at specified time points after `I-123` administration.
`78999`	Unlisted diagnostic radiology procedure (if specific advanced imaging not coded)	Occasionally used for atypical or combined nuclear medicine procedures not represented by a standard code.
`76536`	Ultrasound, soft tissues of head and neck (e.g., thyroid)	Often performed alongside scintigraphy to evaluate nodule size, composition, and guide biopsy decisions.
`10022`	Fine needle aspiration biopsy, with imaging guidance (e.g., ultrasound)	Performed after functional imaging determines a nonfunctioning nodule requiring cytologic evaluation.
`84436`	Thyroid stimulating hormone (TSH) test	Laboratory testing commonly ordered before and after imaging to correlate biochemical status with scintigraphic findings.

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