HCPCS Code A9502

Official Description

Technetium tc-99m tetrofosmin, diagnostic, per study dose

Short Descr	Tc99m tetrofosmin
Coverage	Carrier Priced
Pricing Indicator(s)	57 – Other carrier priced
MPI	A – Not applicable, as HCPCS priced under one methodology
BETOS	I1E – Standard imaging - nuclear medicine
TOS Code(s)	4 – Diagnostic radiology
Added Date	1/1/1998
Status Code	Carriers Price the Code
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Items and Services Packaged into APC Rates
ASC Payment Indicator	Packaged service/item; no separate payment made.
MUE	3
MUE	Not applicable/unspecified.
OTS Orthotic	No
CCS Clinical Classification	243 - DME and supplies

JZ	Zero drug amount discarded/not administered to any patient
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
KX	Requirements specified in the medical policy have been met
GA	Waiver of liability statement issued as required by payer policy, individual case
GC	This service has been performed in part by a resident under the direction of a teaching physician
GW	Service not related to the hospice patient's terminal condition
Q5	Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
GZ	Item or service expected to be denied as not reasonable and necessary
JW	Drug amount discarded/not administered to any patient
26	Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
52	Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53	Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
77	Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR	Catastrophe/disaster related
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
LT	Left side (used to identify procedures performed on the left side of the body)
ME	The order for this service adheres to appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MF	The order for this service does not adhere to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MG	The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
MH	Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
PD	Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PN	Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
QQ	Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure