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Denise Merlino: Let's see. So thanks for the invitation. I'm happy to be here. And I got to tell you, I have so much literature that has come out of these talks over the last few days that it's fabulous for the payers. My disclosures.

And what can I do in eight minutes that will keep you all out of jail? That's the first part. International folks, I apologize right now. If you need your potty break, feel free to go because this is a US-based discussion.

From a very high level, what I'm going to show you is some CPT codes that you can report to your payers. I'm also going to show you very, very basic on the different payer types. Because if any of you come up to me and want to ask a question, I'm going to have to sort through: What setting are you in? Is this an IDTF? Is it a physician office? Is it the hospital outpatient?

So I'll give you a very high-level just one slide on that. I'm also going to give you just two examples because I could talk about this stuff all day long. But I only have my eight minutes.

And then what I thought I'd do, just to save some time, is give you a couple slides that they'll only be up for a few seconds. But they're held for posterity, and that you'll be able to utilize the references, because references are key in this.

And then I'm going to show you some of the basic coding tips. They are my opinion of kind of the high impact. When I do an audit on a facility, what are the ones that I'm actually going to see out there?

So answering the question that I was posed, the title of my talk, Are we getting paid? For Theranostics and Dosimetry? And I can answer, from the folks that I talked to, mostly yes. As with any new procedure, the important part is educating the payers, making sure you have the literature, making sure you're following the appropriate use criteria, making sure that your referrers are educated. So I think those are the key points.

Also, use authoritative sources when you are working with the payers. Obviously, literature is incredibly helpful. But talking to your neighbor who then tells you to code and bill a particular way, that's not an authoritative source.

But authoritative sources are payer policies, CMS, Medicare, and then the medical professional society. So there are a whole host of them for this particular audience. You have ACC, you have SNMMI, you have ACR. So that list goes on and on.

So for this slide, what I wanted to point out is that there are codes in pretty much every section of the book that you all have described in the last day and a half here. And so some of the codes may be in the radiation oncology section. Some of them may be in the nuclear medicine section. Some are in the evaluation and management. Some are in the hydration section.

If you are a physician, if you are performing those services and you are trained in those services, you can use any one of the CPT codes in any one of the sections. So I've heard some folks say, "Oh, I can't use that code because that's in radiation oncology." That's incorrect. That's not the way CPT works.

The way CPT works is it describes a procedure. And if you are trained, you can use that level of code. And it also goes the reverse. I have some folks that say, "That's a nuclear medicine code. I'm a radiation oncologist. I can't use that code." That's actually an incorrect statement.

OK, so here's my slide on the different types of payers. There's the Medicare Physician Fee Schedule out there. And that has a professional and a technical component to it. I may be asking you, if you're in a hospital setting, you may be reporting under the HOPPS setting. And the way I refer to that is it's a mini DRG.

And then there are the third-party payers out there. So if somebody says to me, "I'm not getting paid," I may have to say, OK, so is it Medicare that's not paying you? Is it Aetna? Who's not paying you? And are you not getting paid enough money? Or what's the situation?

So here's my first reference slide. It is a paper by Dr. Stephen Graves with regard to dosimetry. The most important part out of this particular article is it has the CPT code, the description, and then the physician work and the physician time. Take note of that time. If a code has 150 minutes of physician time and you're only taking 10 minutes to do a procedure, you're probably not doing that procedure. Another reference out there for SIRT and Y-90 imaging, another great reference.

So here's my example. And I'm kind of running down on time, so I'm going to speed up a little bit here. But the example is a patient is hydrated for an hour. They got 190.5 millicuries of Pluvicto. I ordered 200 millicuries. That's an important piece you'll hear in just a second.

And then I'm like Tom, and I'm going to do whole-body imaging SPECT. And I'm also going to do two SPECT/CTs of the abdomen and of the pelvis. And so how do I code that?

Well, you have a code for the actual infusion of the radiopharmaceutical. And then you have a code for the Pluvicto. And here's my teaching point right now. That is the number one issue that I find where people are leaving money on the table is that you're coding per millicurie in this particular situation.

And so you have to code 191 units, and then you had a wasted product. So we have decay, and so you append the JW modifier. You put a separate line of the 9 millicuries. There are a lot of sites out there that don't append. They just put what the actual administered dose was. But you paid for 200 millicuries. You should be reimbursed for the 200 millicuries.

And then there are the two codes for the services. And I've got another teaching point here, which is you can bill a whole-body and a SPECT on the same date of service. And so that is what the number one code pair that is allowed in nuclear medicine.

In general, when you're coding and billing for a nuclear medicine procedure, you look to the highest-level service that you do. Is it a SPECT study? What did you actually perform? And you bill just that one code. So that's, in general, how it's done. If I did a couple of SPECT images, if I did a flow, that's generally included in that highest level. So those are the major tips out there.

This is the reference on the use of the waste and the spoilage. And then I'm also going to give you the example of, say you—and I know this probably doesn't happen that often—you order 200 millicuries. You actually gave the patient 200 millicuries. Then you append what's called the JZ modifier. It's just telling the payer that you gave the full amount, and there is no waste.

OK, so I'm running into the red area. So did you get paid what you expected? I want to challenge everybody in this room. It is important to audit yourself. And so just pick five quick cases. Follow the claim all the way through the system. Quite often what you will find is you're either getting paid fine and you don't have to keep auditing, or what you'll find is that a clearinghouse individual or a coder maybe changed that service.

Coding for post-therapy imaging now is where I'm going to get into my rapid fire so that you have the references here. But ensure that there is an order, that it's medically necessary, and that you educate everybody on the value. And I go back to maybe Tom's talk yesterday and how he is passionate about why he's doing the imaging, and that he is comfortable talking to his payer about that.

More references of the different codes that you might be using for dosimetry, again, just emphasizing, as long as the code description, that first descriptor, matches the description of the service—which is actually an example—does not have to match. So it's important that the service matches the amount of time, energy, and effort that you're putting into this, but that the actual example that CPT gives underneath does not have to be an exact match. It's just the code description that has to be the match.

And with that, I'm going to go through just a few references here that talk about the different types of dosimetry you might consider. And I think I have an example of doing a PET.

And so my takeaways here are to report the correct CPT codes and HCPCS codes. And don't leave money on the table. Any new and expensive service out there—we want you to make sure that you check the number of units.

And challenge denials. I can't emphasize enough that a payer on the first go-around is probably going to deny any new type of service because they're just not informed or they have a misconception of what it is that you're trying to do. And so even on the first and the second try, sometimes I've had to talk to them three or four or five times.

But education is what this is all about in order to get paid for what you all in this room are doing, which I think is very important services. And with that, I say thank you. And feel free, if you want the slides, to send me an email.