Summary & Overview
HCPCS A9604: Samarium sm-153 Lexidronam Therapeutic Dose
HCPCS Level II code A9604 designates samarium sm-153 lexidronam, a radiopharmaceutical therapeutic dosed per treatment (up to 150 millicuries) used primarily for palliation of pain from bone metastases. As a specialized oncology drug administered in outpatient infusion or hospital-based settings, coverage and reimbursement practices for A9604 affect access to targeted pain-relief therapies across the country. National payers typically address this code within medical oncology and radiation therapy benefit designs.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, expected site-of-service, and the types of benchmarks and policy elements commonly associated with this radiopharmaceutical code. The publication summarizes typical payer coverage considerations, coding and billing modifiers commonly applied, and where stakeholders seek guidance when documenting therapeutic radiopharmaceutical administration.
This report provides clinicians, billing specialists, and policy analysts with a clear reference to the code’s clinical purpose and operational implications, including what to expect in site-of-service deployment, common modifier usage, and the payer landscape nationally. Data not available in the input will be noted where relevant.
Billing Code Overview
HCPCS Level II code A9604 represents samarium sm-153 lexidronam, a radiopharmaceutical agent provided as a therapeutic infusion for pain palliation in patients with bone metastases. The code describes the drug per treatment dose, up to 150 millicuries.
Service Type: Therapeutic radiopharmaceutical administration
Typical Site of Service: Hospital outpatient infusion center or specialty cancer treatment facility
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Clinical & Coding Specifications
Clinical Context
A typical patient is an older adult with metastatic castration-resistant prostate cancer presenting with symptomatic bone pain from multiple osseous metastases. The oncology team evaluates the patient for targeted radiopharmaceutical therapy using samarium sm-153 lexidronam for palliation of diffuse painful bone lesions. Prior to treatment, the patient undergoes hematologic assessment (CBC with differential), renal and hepatic function tests, and a bone scan or PET/CT to confirm extent and distribution of osteoblastic metastases. The clinical workflow includes informed consent, coordination with nuclear medicine/radiopharmacy to order and prepare A9604 (samarium sm-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries), baseline pain assessment, venous access placement, administration of the radiopharmaceutical in a nuclear medicine suite or hospital outpatient infusion/service area, radiation safety monitoring, post‑administration observation for acute reactions, and documentation of dose, lot number, route, and patient response in the medical record. Follow-up visits monitor pain relief, performance status, and repeat laboratory testing to detect marrow suppression; additional therapeutic doses are considered based on clinical response and hematologic recovery.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
JW | Drug discarded/not administered to any patient | When a portion of a multi-dose vial or pre-drawn dose is wasted and must be reported per payer policy |