Summary & Overview
HCPCS A9596: Gallium Ga-68 Gozetotide (Illuccix), Diagnostic, 1 mCi
HCPCS Level II code A9596 denotes Gallium Ga-68 gozetotide (Illuccix), a diagnostic radiopharmaceutical measured per 1 millicurie. This agent is used in nuclear medicine for PET imaging of somatostatin receptor–positive lesions and is increasingly relevant as advanced molecular imaging expands diagnostic precision in oncology and neuroendocrine tumor management. Nationally, accurate coding and billing for radiopharmaceuticals like A9596 affect access to PET imaging, provider reimbursement, and utilization monitoring.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The analysis addresses how these payers handle coverage and billing for radiopharmaceuticals, focusing on common payment considerations and the implications for imaging providers.
Readers will find benchmarks for coding and payment practice, a summary of relevant policy and coverage themes, and clinical context for when A9596 is used. The publication highlights practical billing considerations for institutional and outpatient settings and summarizes policy developments that influence access to Gallium Ga-68 gozetotide PET imaging. Data not available in the input will be identified where applicable.
Billing Code Overview
HCPCS Level II code A9596 represents Gallium Ga-68 gozetotide, diagnostic, (Illuccix), 1 millicurie, a radiopharmaceutical used for diagnostic imaging. This product is administered as a radioactive tracer for molecular imaging studies that target somatostatin receptor–expressing lesions.
-
Service type: Diagnostic radiopharmaceutical administration
-
Typical site of service: Hospital outpatient imaging department, outpatient nuclear medicine facility, or ambulatory imaging center
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 68-year-old male with a history of treated prostate cancer presents with rising prostate-specific antigen (PSA) and suspicion for recurrent or metastatic disease. The referring medical oncologist orders a diagnostic PET scan using A9596 (Gallium Ga-68 gozetotide, diagnostic, (Illuccix), 1 millicurie) to localize somatostatin receptor–expressing lesions for restaging. The typical clinical workflow: the radiology or nuclear medicine clinic verifies indication and performs pre-procedure screening, obtains informed consent, and confirms recent laboratory tests and allergy history. The technologist prepares and administers the radiopharmaceutical A9596 intravenously in the nuclear medicine injection area. The patient rests per protocol to allow tracer distribution, then proceeds to PET/CT imaging in the nuclear medicine suite. Images are reconstructed and interpreted by a nuclear medicine physician or radiologist; a diagnostic report is generated and communicated to the referring provider. Typical sites of service are an outpatient hospital imaging department, ambulatory imaging center, or a hospital inpatient nuclear medicine department when inpatient staging is required. Common patient scenarios include biochemical recurrence of prostate cancer, staging for suspected neuroendocrine tumors, or evaluation of localized disease when conventional imaging is inconclusive.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier (default) | Routine reporting when no modifier is applicable |
22 | Unusual procedural services | When work required is substantially greater than typical for the procedure (rare for radiopharmaceutical dispensing/administration) |
23 | Unusual anesthesia | When medically necessary anesthesia is provided for an otherwise non-anesthetic procedure |
52 | Reduced services | If only a partial dose or abbreviated imaging protocol is performed |
53 | Discontinued procedure | When the administration or imaging is started but stopped for patient safety or other valid reasons |
62 | Two surgeons | When two physicians of different specialties share performance responsibility (rare for radiopharmacy but applicable if shared procedural care occurs) |
78 | Unplanned return to OR/procedure | For an unplanned repeat interventional procedure related to complications (uncommon for diagnostic radiopharmaceuticals) |
80 | Assistant surgeon | When an assistant surgeon is legitimately required (rare for diagnostic PET administration) |
AS | Physician assistant, nurse practitioner, or clinical nurse specialist services | When a PA/NP/CNS performs or assists in administration under state law and payor policy |
JW | Drug discarded/not administered to any patient | When part of the A9596 vial is discarded and reporting of waste is required by payor |
JZ | No drug wastage (no waste) | When an entire unit of A9596 is used with no waste |
QX | CRNA service with medical direction by physician | If a certified registered nurse anesthetist provides anesthesia for the procedure under medical direction |
QY | Medical direction of two, three, or four anesthesia procedures | When the physician medically directs multiple anesthesia procedures during the imaging session |
UD | Urine drug screen (facility-specific) | When facility-specific urine or point-of-care testing is performed prior to imaging (used per facility policy) |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
2084P0800X | Nuclear Medicine Physician | Interprets PET/CT images and supervises radiopharmaceutical administration |
207RC0000X | Diagnostic Radiology | Radiologist who may interpret fused PET/CT studies and provide diagnostic correlation |
364S00000X | Radiology Technician (Nuclear Medicine Technologist) | Prepares and administers radiopharmaceutical, performs imaging acquisition |
208D00000X | Interventional Radiology (when applicable) | Involved if image-guided biopsy or intervention is planned in same encounter |
163WL0500X | Medical Oncology | Refers and uses PET results for cancer staging and treatment planning |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
C61 | Malignant neoplasm of prostate | Common indication for Ga-68 prostate-specific membrane antigen (PSMA)–targeted PET imaging to detect recurrent or metastatic disease |
C77.0 | Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck | Lymph node metastasis localization may be assessed with PET imaging using A9596 |
C79.5 | Secondary malignant neoplasm of bone | Bone metastases from prostate cancer or other tumors are routinely evaluated with PET/CT after A9596 administration |
D37.9 | Neoplasm of uncertain or unknown behavior of urinary system | Used when localization or characterization of suspected prostate/urothelial lesions is required |
R97.2 | Elevated prostate specific antigen (PSA) | Biochemical recurrence prompting PSMA-targeted PET with A9596 to localize disease |
C7A.89 | Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue | When evaluating unusual metastatic patterns or neuroendocrine-type lesions that may express target receptors |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
78813 | PET imaging, tumor, single area; with concurrently acquired CT for attenuation correction and anatomic localization, including imaging supervision, interpretation, and report | Common PET/CT acquisition code used when A9596 is administered for tumor localization in a single region |
78816 | PET imaging, tumor, multiple areas; with concurrently acquired CT for attenuation correction and anatomic localization, including imaging supervision, interpretation, and report | Used when whole-body or multiple-region PET/CT imaging is performed after administration of A9596 |
78815 | PET imaging, tumor; whole body, with concurrently acquired CT for attenuation correction and anatomic localization, including imaging supervision, interpretation, and report | Applicable for whole-body staging protocols following A9596 administration |
79705 | Injection procedure for administration of radiopharmaceutical agent via intravenous route (includes venous access) | Procedure code for the intravenous injection of A9596 when separately reportable under payer policy |
76376 | CT attenuation correction and anatomic localization for PET/CT, performed in conjunction with PET | Describes the CT component used for attenuation correction and anatomic localization of PET images acquired after A9596 administration |