CurrentBlue Cross Blue Shield - WisconsinPolicy C-24001

Diagnostic Radiopharmaceuticals and Contrast Materials - Professional and Facility

Governs reimbursement for diagnostic radiopharmaceuticals and contrast materials for professional and facility settings under the payer's commercial reimbursement policies, including inpatient and outpatient facility settings and professional providers reporting services in a facility place of service.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyDiagnostic Radiopharmaceuticals and Contrast Materials - Professional and Facility

Policy CodePolicy C-24001

Change TypeRevised (Colorado coding exception)Policy creation/restructuringClarification

Effective DateMay 1, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and the member's state of residence.

SourceLink

POLICY UPDATE CHANGES

Updated Colorado exemption to allow A9595 and A9596 and removed Q9967 to align with guidelines.

Removed professional language from prior Place of Service - Professional policy and created this new combined policy C-24001.

Therapeutic radiopharmaceuticals are excluded from the facility prohibition and may be separately reimbursed.

inpatient/outpatientfacility settings covered

not allowedseparate reimbursement (facility)

restricted

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Reimbursement and Coverage Criteria

Reimbursement criteria

Covered when the following reimbursement rules and exceptions apply:

ALL of the following

ALL of the following
- The health plan does not allow separate reimbursement for diagnostic radiopharmaceuticals and contrast materials and/or media in a facility setting unless provider, state, federal contract and/or requirements indicate otherwise.
- Diagnostic radiopharmaceuticals and contrast materials are considered an integral component to the diagnostic service and will not be reimbursed separately to the facility.
ALL of the following
- Therapeutic radiopharmaceuticals are excluded from the facility prohibition and are allowed for separate reimbursement.
ALL of the following
- The health plan does not allow separate reimbursement for radiopharmaceutical and contrast materials by professional providers when reported in a facility place of service.
State-specific exceptions
- Colorado facility exception: Anthem Blue Cross and Blue Shield allows separate reimbursement for specified HCPCS codes when billed by a facility (see Related Coding exceptions for list of codes).
  Related Coding exceptions list A9584, A9587, A9588, A9595 and A9596 for Colorado; policy history updated Colorado exemption to allow A9595 and A9596 and removed Q9967.
- Other states: Policy applies unless provider, state, federal contract and/or requirements indicate otherwise; refer to payer/state guidance for Kentucky and Wisconsin applicability as noted in policy metadata.

ALL of the following

Standard correct coding applies; bill with appropriate CPT, HCPCS and revenue codes and support claims in the medical record. Noncompliant claims may be rejected, denied, or recouped.

Related Coding and Exceptions

Related Coding exceptionsHCPCSCovered

A9584	Related diagnostic radiopharmaceutical HCPCS code (per Related Coding exceptions)
A9587	Related diagnostic radiopharmaceutical HCPCS code (per Related Coding exceptions)
A9588	Related diagnostic radiopharmaceutical HCPCS code (per Related Coding exceptions)
A9595	Diagnostic radiopharmaceutical - Colorado facility exception
A9596	Diagnostic radiopharmaceutical - Colorado facility exception

Colorado facility exception — allowed codes

Facility exception — allowed HCPCSA9584, A9587, A9588, A9595 and A9596 are allowed for separate reimbursement when billed by a facility in Colorado.

State applicabilityColorado: separate reimbursement allowed for listed codes; Kentucky and Wisconsin: policy does not apply to facility providers.

Coding guidanceStandard correct coding applies when billing these HCPCS codes in Colorado facilities.

Authorization, Medical Necessity, and Billing Actions

Prior Authorization

Prior authorization, medical necessity, and billing requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence. Use proper billing and submission guidelines, including CPT, HCPCS and/or revenue codes, and ensure claims are fully supported in the medical record or office notes. Noncompliance with coding/billing or reimbursement policies may result in claim rejection or denial, and the plan may recover or recoup payment.

Obtain any required prior authorization and ensure the service meets medical necessity for the procedure, diagnosis, and member’s state of residence.
Bill with appropriate CPT, HCPCS and/or revenue codes and document supporting clinical information in the medical record or office notes.
Be aware that failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection/denial or recovery/recoupment of payment.

Definitions

Contrast materials

DefinitionDyes or other substances that temporarily change the way x-rays or other imaging tools interact with the body.

Context in policyContrast materials are considered an integral component of the diagnostic service and are not separately reimbursable in facility settings (policy scope).

Claiming noteSeparate reimbursement for contrast materials is not allowed when reported in a facility place of service (see reimbursement criteria).

Diagnostic radiopharmaceuticals

DefinitionRadioactive agents that are administered in small doses to diagnose certain medical problems or diseases.

Policy stanceDiagnostic radiopharmaceuticals are considered integral to the diagnostic service and are not separately reimbursable in facility settings.