A9594 Gallium Ga-68 PSMA-11 HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS A9594: Gallium Ga-68 PSMA-11 Diagnostic PET, 1 mCi

HCPCS Level II code A9594 denotes a single 1 millicurie dose of Gallium Ga-68 PSMA-11 for diagnostic PET imaging, a radiopharmaceutical used to localize prostate cancer via PSMA-targeted imaging. Nationally, PSMA PET tracers have grown in clinical importance for staging, recurrence detection, and guiding management in prostate cancer patients, making accurate coding and coverage understanding essential for providers and payers.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of payer coverage patterns and typical reimbursement contexts (where available), clinical context for use of the tracer in PET imaging, and the operational aspects relevant to billing a radiopharmaceutical dose. The publication also outlines common modifiers associated with services of this type and notes where input data were not provided.

This summary equips billing managers, radiology administrators, and policy analysts with a concise reference to the clinical purpose of A9594, the service settings where it is typically administered, and the payer landscape addressed in the accompanying sections.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareA9594HCPCS Level IIradiopharmaceuticalPSMA PETnuclear medicinediagnostic imaginggallium ga-68prostate cancerPET imaging

Billing Code Overview

HCPCS Level II code A9594 describes Gallium Ga-68 PSMA-11, diagnostic, (UCLA), 1 millicurie. This code represents a radiopharmaceutical dose of Gallium Ga-68 PSMA-11 used for diagnostic PET imaging targeting prostate-specific membrane antigen (PSMA), commonly utilized in the evaluation of prostate cancer.

Service type: Diagnostic radiopharmaceutical administration for PET imaging
Typical site of service: Outpatient imaging centers, hospital outpatient departments, and nuclear medicine or PET suites

Clinical & Coding Specifications

Clinical Context

A 68-year-old male with biochemical recurrence of prostate cancer following radical prostatectomy is referred for a targeted prostate-specific membrane antigen (PSMA) PET scan using Gallium Ga-68 PSMA-11 (billing code A9594) to localize sites of recurrent disease. The clinical workflow begins with ordering by a urologist or medical oncologist, documentation of the indication (rising prostate-specific antigen), and scheduling with a nuclear medicine or radiology outpatient PET/CT facility. On the day of service, the radiopharmacy prepares a 1 millicurie dose of Gallium Ga-68 PSMA-11 under sterile radiopharmaceutical handling protocols. The patient arrives fasting per site protocol, IV access is obtained, and the tracer is administered intravenously. After an uptake period (typically 45–60 minutes), the patient undergoes whole-body PET/CT imaging. The interpreting nuclear medicine physician reviews images, generates a diagnostic report describing PSMA-avid lesions, and communicates results to the referring provider for treatment planning (e.g., salvage radiotherapy, systemic therapy, or metastasis-directed therapy). Typical sites of service include outpatient hospital-based nuclear medicine departments, freestanding imaging centers, and academic medical centers. Typical providers involved are nuclear medicine physicians, radiopharmacists, PET technologists, and referring urologists or medical oncologists. Common clinical scenarios include localization of recurrent prostate cancer with low but rising PSA levels, staging in high-risk prostate cancer, and evaluation of suspected oligometastatic disease for targeted interventions.

Coding Specifications

Modifier	Description

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

HCPCS-A9268-PROGRAMMER-TRANSIENT-INGESTED-CAPSULE

HCPCS A9268: Programmer for Transient Orally Ingested Capsule

HCPCS-A9508-IODINE-I131-IOBENGUANE-DIAGNOSTIC-0-5-MCI

HCPCS Level II A9508: Iodine I-131 iobenguane sulfate, Diagnostic

HCPCS-A9282-WIG-SUPPLY

HCPCS Level II A9282: Wig, Any Type, Each

HCPCS-A9558-XENON-VENTILATION-GAS-DIAGNOSTIC

HCPCS A9558: Xenon Xe-133 Gas for Diagnostic Ventilation Imaging

HCPCS-A9561-TECHNETIUM-TC-99M-OXIDRONATE-BONE-IMAGING

HCPCS A9561: Technetium tc-99m Oxidronate for Bone Imaging

HCPCS-A9563-SODIUM-PHOSPHATE-P32-THERAPEUTIC-PER-MILLICURIE

HCPCS A9563: Sodium Phosphate P-32 Therapeutic, Per Millicurie

HCPCS-A9532-IODINE-I-125-SERUM-ALBUMIN-DIAGNOSTIC

HCPCS A9532: Iodine I-125 Serum Albumin, Diagnostic, per 5 microcuries

HCPCS-A9153-MULTIVITAMIN-ORAL-PER-DOSE

HCPCS A9153: Multiple Vitamins, Oral, Per Dose

HCPCS-A9545-IODINE-I-131-TOSITUMOMAB-THERAPEUTIC-DOSE

HCPCS Level II A9545: Iodine I-131 Tositumomab, Therapeutic Dose

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Taxonomy Code	Specialty	Notes
`2085R0200X`	Nuclear Medicine Physician	Primary interpreting physician for PSMA PET imaging
`208D00000X`	Diagnostic Radiology	Radiology departments that manage PET/CT operations and interpretation
`3336S0005X`	Radiopharmacist	Prepares and dispenses radiopharmaceuticals according to regulations
`246U00000X`	Physician Assistant	May assist in coordination, consent, and some clinical documentation
`390200000X`	Medical Oncology	Referring specialty commonly ordering PSMA PET for staging and recurrence decisions

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C61`	Malignant neoplasm of prostate	Primary diagnosis for which PSMA PET is used for staging or detection of recurrence
`N90.89`	Other specified atrophy of vulva and perineum	Data not clinically relevant to this procedure; included to respect input constraints
`R97.2`	Elevated prostate specific antigen [PSA]	Common indication for ordering PSMA PET to localize recurrent or residual prostate cancer when PSA rises after definitive therapy
`C79.5`	Secondary malignant neoplasm of bone and bone marrow	PSMA PET is commonly used to detect osseous metastases from prostate cancer
`C79.82`	Secondary malignant neoplasm of adrenal gland	PSMA PET may detect uncommon metastatic sites such as adrenal involvement

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`78815`	Positron emission tomography (PET) for tumor imaging, whole body, single day; 1 or more areas, using combined imaging with concurrently acquired CT for attenuation correction and anatomic localization	Common imaging CPT for whole-body oncologic PET/CT that is performed with the administered `Gallium Ga-68 PSMA-11` tracer; technical and professional components map to PET/CT workflow
`78816`	Positron emission tomography (PET) for tumor imaging, limited area; single area, single day	Used when limited-area PET/CT (e.g., pelvis and abdomen) is performed instead of whole-body imaging
`G0218`	PET attenuation correction and localization CT performed without contrast (non-specific)	Used when a low-dose CT for attenuation correction is performed as part of PET/CT acquisition (site-dependent reporting)
`A9517`	Injection, radiopharmaceutical, diagnostic, (specify radioisotope), 1 mCi	Administrative or payer-specific HCPCS sometimes used for reporting radiopharmaceutical injection quantities; useful for reconciliation though `A9594` is the specific Gallium PSMA code
`S8080`	Radiopharmaceutical, diagnostic, Gallium Ga-68 PSMA-11 (local or site-specific code examples vary)	Alternate/system-specific code sometimes used in institutional charge master alongside `A9594` for internal billing reconciliation

`00`	No modifier	Use when no special circumstance modifier applies
`22`	Increased procedural services	Use when work required is substantially greater than normally required for radiopharmaceutical preparation or administration and properly documented
`23`	Unusual anesthesia	Use if unusual anesthesia is required for patient tolerance during imaging (rare for PET)
`52`	Reduced services	Use when the study is partially reduced or not completed but still billed
`53`	Discontinued procedure	Use when the procedure is started but discontinued for patient safety reasons
`62`	Two surgeons	Use when two physicians of different specialties are documented as performing distinct portions of the service (rare for PET)
`80`	Assistant surgeon	Use if an assistant surgeon is documented (unlikely for diagnostic PET)
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist report	Use when the service or portion is provided by an advanced practice clinician as permitted by payer rules
`TC`	Technical component	Use to bill only the technical component (radiopharmaceutical, imaging equipment, technologist) when the interpreting physician bills separately
`26`	Professional component	Use to bill only the professional component when the facility bills the technical portion (Note: `26` is not in the provided modifier list; use `TC`/global accordingly)

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