MEDICARE BILLING FOR BRACHYTHERAPY SOURCES

Radioactive sources used in brachytherapy treatment are available in many different forms such as seeds, needles, wires, ribbons, pellets or liquids. Medicare coding and billing for brachytherapy sources (also known as brachytherapy seeds, radioelements, devices) is unique to the site-of-service.

Physician Office or Freestanding Center

The brachytherapy source(s) is reimbursed when billed in an office or freestanding center (site-of-service 11) using HCPCS Q3001.

Q3001 Radioelements for brachytherapy, any type, each

HCPCS Q3001 may be used to recover the cost of expendable radioelements such as Iodine-125, Palladium-103 and Cesium-131 sources. Only the entity that bears the cost of purchasing the brachytherapy source(s) may bill this code. Sources used for remote afterloading high intensity brachytherapy (also known as High Dose Rate Brachytherapy) are not separately payable in the office or freestanding center setting.

For Medicare, HCPCS Q3001 is “carrier-priced.” There is no national Medicare payment rate for Q3001. The carrier has the discretion to assign a price. When the service is performed in the physician's office or freestanding center, the correct method to report the sources is the following:

• Report the number of sources in the “units” field.
• Documentation consists of provision of a brachytherapy device acquisition invoice.

It is recognized that a small number of additional seeds may be ordered and billed to cover plan changes or intraoperative loss.

Hospital Outpatient Department and Ambulatory Surgical Center

Medicare makes separate payment for both Low Dose Rate (LDR) and High Dose Rate (HDR) sources in addition to brachytherapy treatment delivery when provided in a hospital outpatient department or ambulatory surgical center (ASC).

CMS has designated HCPCS Level II codes for separately reimbursed radiation sources to report stranded (embedded into the stranded suture material and separate within the strand by material of an absorbable nature at specific intervals) and non-stranded sources. If facilities use both stranded and non-stranded sources for the same patient, they can separately report each type of service.

The following codes should be used to report sources in the hospital outpatient setting.

HCPCS	Long Descriptor
A9527	Iodine I-125, sodium iodide solution, therapeutic, per mCi
C1716	Brachytherapy source, Gold-198, per source
C1717	Brachytherapy source, High Dose Rate Iridium-192, per source
C1719	Brachytherapy source, Non-High Dose Rate Iridium-192, per source
C2616	Brachytherapy source, Yttrium-90, per source
C2634	Brachytherapy source, High Activity, Iodine-125, greater than 1.01 mCi (NIST), per source
C2635	Brachytherapy source, High Activity, Palladium-103, greater than 2.2 mCi (NIST), per source
C2636	Brachytherapy linear source, Palladium-103, per 1MM
C2637	Brachytherapy source, Ytterbium-169, per source
C2638	Brachytherapy source, stranded, Iodine-125, per source
C2639	Brachytherapy source, non-stranded, Iodine-125, per source
C2640	Brachytherapy source, stranded, Palladium-103, per source
C2641	Brachytherapy source, non-stranded, Palladium-103, per source
C2642	Brachytherapy source, stranded, Cesium-131, per source
C2643	Brachytherapy source, non-stranded, Cesium-131, per source
C2644	Brachytherapy source, Cesium-131 chloride solution, per mCi
C2645	Brachytherapy planar source, Palladium-103, per square millimeter

Brachytherapy sources are paid separately from the services to administer and deliver brachytherapy in the hospital outpatient and ASC setting. Payment reflects the number, isotope and radioactive intensity of devices furnished, as well as stranded versus non-stranded configurations of sources. Seed-like sources are generally billed and paid “per source” based on the number of units of the HCPCS source code reported, including the number of sources within a stranded configuration. It is important to use the source specific C-code that best describes the radioelement used. Note that when billing for stranded sources, providers should bill the number of units of the appropriate source HCPCS C-code according to the number of brachytherapy sources in the strand, and should not bill as one unit per strand.

In the case where most, but not all, prescribed sources are implanted in the patient, Medicare will pay for the relatively few brachytherapy sources that are ordered but not implanted. The hospital may charge for all sources if they are specifically acquired by the hospital for the particular patient according to a physician's prescription, in order to ensure that the clinically appropriate number of sources are available and not implanted in any other patient. Sources not implanted must be correctly disposed of, and the sources would typically constitute a small fraction of the total ordered.

For Medicare patients, the hospital may report the codes for brachytherapy needles and catheters. No additional payment will be made for these devices; however, they will be used to track the cost for future ambulatory payment classification (APC) rate calculations. Your hospital may itemize miscellaneous supplies on bills by using revenue codes. If you use revenue codes, the specific date of service should appear with each code. By providing the date of service it will allow Medicare to set payment rates more accurately in the future.

• C1715 Brachytherapy needle
• C1728 Catheter, brachytherapy seed administration

Physicians (and physician offices or freestanding centers) should not bill these codes because the codes only apply to the hospital outpatient setting.

How to Calculate Charges for Brachytherapy Sources

The actual reimbursement for sources in hospital outpatient departments and ambulatory surgical centers is based on cost and charge data that is reported by individual departments and centers. The reimbursements each year are based upon the date that was submitted two years earlier.

Below are suggestions on how to calculate charges for single use brachytherapy sources so that you receive future reimbursement for the sources at their full cost.

• Step 1: Determine your cost per source for each source type that you use in your hospital.
• Step 2: Find out your hospital's cost-to-charge ratio from the department in your hospital that is responsible for completing the annual cost report. This is often the finance department. The cost-to-charge ratio is calculated by summing all the Medicare allowable costs across departments and dividing this by all the charges billed to patients. The fiscal intermediary that processes your claims should also have this number.
• Step 3: Divide the cost from step 1. by the cost-to-charge ratio from step 2. To receive reimbursement from Medicare for the cost of the source this is the amount that should be recorded as a charge on your charge master.

In order to recover any departmental overhead costs, the charge would need to be more than these calculated amounts. Remember the charges for the single use sources are per source, so you must enter the number of sources used on each claim in the “units” field.

The radiation source or brachytherapy seed is billed based on the type used. Don't forget to bill the correct number of units! Medicare will pay you per source, so it is very important to make sure the number of sources used is indicated in the “units” field of your billing system. It is appropriate to bill for all the sources ordered for an individual patient, even if some are wasted and not implanted in the patient.

Determining a charge for High Dose Rate Iridium-192 (C1717) is a bit more complicated, because these sources are used for multiple patients. HCPCS code C1717 is the source used in HDR remote after-loading procedures. This source will also be paid by Medicare by multiplying your charge and your hospitals cost-to-charge ratio.

In order to cover your costs for this source you need to set your charge carefully. The following steps will help you determine an accurate charge for HCPCS C1717. This is estimated on your utilization and costs for a quarter. It calculates a charge that will result in reimbursement of your direct costs for the source. If you need to recover administrative overhead the charge would need to be higher. These charges are calculated per treatment, when billing a single treatment the number of units should be one.

• Step 1: Average number of patients treated with HDR per quarter.
• Step 2: Estimated number of treatment fractions per patient.
• Step 3: Estimated number of treatment fractions per quarter (Line 1 multiplied by Line 2).
• Step 4: Estimated quarterly service and source costs. If you have a service agreement, enter the quarterly cost of the service agreement and any other service related costs. If you do not have a service agreement, enter your estimate of the quarterly preventive maintenance and source costs.
• Step 5: Calculate the average cost per treatment fraction (Divide Line 4 by Line 3).
• Step 6: Enter your hospitals cost-to-charge ratio.
• Step 7: Estimate the charge needed to recover direct costs of the source (Divide Line 5 by Line 6).

Setting Medicare charges for brachytherapy sources accurately is important so that your facility does not lose money. Medicare pays for brachytherapy sources by multiplying the hospital's charge as it appears on the claim by the hospital's cost-to-charge ratio as calculated from the cost report. If your charge is the published payment rate, your payment will be reduced below this charge based on your hospital's average mark-up over costs.

Complete and correct brachytherapy source coding and setting accurate charges for each source significantly impacts hospital payment and the ability to offer brachytherapy to Medicare beneficiaries.