Reimbursement

ABN - Advanced Beneficiary Notice. A form providing written notification to the Medicare patient, prior
to a procedure, that the procedure may not be covered (paid) by Medicare. Medicare will pay only for
services that it determines to be reasonable and necessary under Section 1862 (a) (1) of Medicare Law.
Documentation of the ABN notification is necessary if you wish to bill the patient directly for services.

ACC - American College of Cardiology. A national organization established in 1949 whose mission is to
foster optimal cardiovascular care and disease prevention through professional education, to promote
research, to provide leadership in development of standards and guidelines, and to formulate healthcare
policy. (www.acc.org)

ACR - American College of Radiology. A national organization, founded in 1923, composed of physicians
and radiological physicists who specialize in the use of X-ray, Ultrasound, Nuclear Medicine,
Magnetic Resonance, and other imaging modalities for the diagnosis of disease and for the treatment
and management of cancer. (www.acr.org)

AHA - American Heart Association. A national voluntary health agency whose mission is to reduce disability
and death from cardiovascular diseases and stroke. (www.americanheart.org)

AHA - American Hospital Association. A national organization, founded in 1898, to help members provide high-quality healthcare and to represent America’s hospitals. The association includes 15 other affiliated societies that promotes research and education projects in many healthcare areas (administration, economics, community relations), represent hospitals regarding national legislation; offers members services in healthcare planning, hospital organization, healthcare financing, and provides programs for institutional effectiveness review. (www.aha.org or www.hospitalconnect.com)

AHCPR - Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality (see AHRQ).

AHRA - American Healthcare Radiology Administrators. A national organization composed of Radiology Administrators that focuses on hospital management. (www.ahraonline.com)

AHRQ - Agency for Healthcare Research and Quality, established in December 1989 as a part of the Department of Health and Human Services. The agency’s mission is to enhance the quality, appropriateness, and effectiveness of healthcare services; to reduce healthcare cost; and to broaden access to essential services. Its research programs bring practical science-based information to medical practitioners and consumers. AHRQ directs the scientific review process for grants and evaluates the medical contribution of proposed and ongoing research. (www.ahrq.gov)

AMA - American Medical Association. A national organization of physicians and county medical societies founded in 1847 for the purposes of distributing information to members and to the public, keeping members informed of medical health legislation on the state and national levels, representing the profession before Congress and government agencies, cooperating in the setting of standards for medical schools and continuing medical education courses, and offering publications such as JAMA. (www.ama-assn.org)

AMI - Academy of Molecular Imaging, formerly called the Institute of Clinical PET (ICP), reorganized and renamed in 2001. A nonprofit educational foundation founded in 1991 to promote the use of noninvasive, diagnostic positron imaging for measuring the metabolic activity of cells in the human body. (www.ami-imaging.org)

APC - Ambulatory Payment Classification, first implemented in August 2000, replacing the reasonable cost payment system for hospital outpatient procedures. The APC system is a prospective payment system that is unit based similar to RBRVS. It is an averaging system intended to provide incentive to hospitals to keep costs down and to reduce government spending. The services within each APC grouping are similar clinically and require similar use of resources. Payments are assigned to each APC based on resource utilization. APCs are part of the Hospital Outpatient Prospective Payment System (HOPPS).

ARRT - American Registry of Radiologic Technologists. A national organization founded in 1922 for the purposes of identifying individuals qualified in the safe and effective application of X-rays for medical purposes and for providing certification for Nuclear Medicine technologists, radiologic technologists, and radiation therapy technologists. (www.arrt.org)

ASNC - American Society of Nuclear Cardiology. A professional medical society whose mission is to foster optimal delivery of nuclear cardiology services through the development of standards of professional education and training, to establish guidelines for the clinical performance of nuclear cardiology, and to promote nuclear cardiology research. (www.asnc.org)

ASRT - American Society of Radiologic Technologists. A national organization, founded in 1920, of technologists in Diagnostic Radiology, Radiation Therapy, Ultrasound, and Nuclear Medicine who are interested in advancing the science of radiologic technology and establishing and maintaining high standards of education and training in the field. (www.asrt.org)

BBRA - Balanced Budget Refinement Act of 1999. A law allowing for, among other things, separate transitional payment of radiopharmaceuticals for at least two years, but not exceeding three years in the new APC system.

Carriers - Payers who have a contract with CMS to administer the RBRVS system to physician offices, IDTFs, or imaging centers. A carrier processes claims, provides training/educational services, and issues payment on behalf of CMS. Carriers have local discretion in the absence of national policies.

CCI - Correct Coding Initiative. A software program used by Medicare to promote correct coding for Medicare reimbursement. (http://www.cms.hhs.gov)

CMS - Center for Medicare and Medicaid Services. Effective June 2001, the Health Care Financing Administration (HCFA) was renamed CMS. The HCFA, part of the US Department of Health and Human Services (HHS), was created in 1977 to administer the Medicare and Medicaid programs; establish policies for the reimbursement of healthcare providers; and conduct research on the effectiveness of various methods of healthcare management, treatment, and financing. (www.cms.hhs.gov)

CORAR - Council of Radionuclides and Radiopharmaceuticals. An organization of industry representatives interested in legislative issues related to radiopharmaceuticals and radionuclides. Activities include monitoring and lobbying federal agencies such as the FDA, CMS, NIH, and NRC. (www.corar.org)

CPT Codes - Physicians’ Current Procedural Terminology. A manual that lists descriptive terms and identifying codes used to report medical services and procedures by physicians offices. The codes are five (5) digit numeric characters. The CPT manual is copyrighted to the AMA and is updated annually.

CSNM - Canadian Society of Nuclear Medicine (www.csnm.medical.org)

DHHS - Department of Health and Human Services. A federal agency that includes the Center for Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), The Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH). (www.hhs.gov)

DRGs - Diagnosis-Related Groups. A classification of healthcare services mandated by the Social Security Amendments of 1983. The DRG system is the basis for the prospective payment rates for Medicare’s inpatient prospective payment system. Classifications are based on principal diagnosis, secondary diagnosis, surgical procedures (if any), sex, age, and presence of complications. Groupings of diagnostic categories are drawn from the ICD-9-CM. The DRG system is used as a financial mechanism to reimburse hospitals for inpatient services rendered. The amount paid under the system is based on the average charge for treating a particular condition.

EANM - European Association of Nuclear Medicine. (www.eanm.org)

EOMB - (or EOB) Explanation of Medicare Benefit. A remittance given to patients and/or physicians that confirms payment of a claim or explains why a payment was reduced or denied.

EPA - Environmental Protection Agency. A federal agency whose mission is to protect public health and to safeguard and improve the natural environment. Its purpose is to ensure that federal environmental laws are implemented and enforced. The disposal of nuclear materials from Nuclear Medicine departments falls under the jurisdiction of the EPA. (www.epa.gov)

FDA - Food and Drug Administration. An agency that ensures the safety of foods and cosmetics and the safety and efficacy of pharmaceuticals, biological products, and medical devices. All radiopharmaceuticals used in Nuclear Medicine undergo rigid testing before approval for use in the general population. (www.fda.gov)

FI – Fiscal Intermediary. A payer contracted by CMS to administer the DRG and APC systems. An FI processes claims, provides services, and issues payments on behalf of certain private, federal, and state health benefit programs or other insurance organizations. FIs have local discretion in the absence of national policies.

HCPCS Codes - Healthcare Common Procedural Coding System. A coding system governed by CMS that includes level II national codes, which are five-digit alphanumeric codes frequently used to denote drugs, supplies, medical equipment, and nonphysician services and procedures.

HCFA - Health Care Financing Administration. This is the former name of the Center for Medicare and Medicaid Services (See CMS).

HIPAA - Health Insurance Portability and Accountability Act of 1996. A comprehensive law that addresses patients’ rights to privacy, permits “portability” of health coverage when changing jobs, and establishes administrative simplification processes.

HOPPS - Hospital Outpatient Prospective Payment System. The Medicare payment system for most hospital outpatient services. The unit of payment under HOPPS is the Ambulatory Payment Classification (APCs).

ICD-9-CM - International Classification of Diseases, Ninth Revision, Clinical Modifications. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is used for inpatient and ambulatory diagnoses and for the inpatient procedure coding. ICD-9-CM Volumes I & II are used for the coding of all diagnoses (in any setting: hospital, ambulatory care centers, physician offices, etc.). ICD-9-CM Volume III should be used for coding all inpatient procedures. Volume I- A tabular list of illnesses, injuries, diseases, signs, symptoms, and ill-defined conditions. Listed numerically.
Volume II – An alphabetic index of diseases and injuries. Volume III – A tabular list and alphabetic Index for surgery and procedures. Listed numerically. Conversion to ICD-10-CM may occur in the next few years.

IDTF - Independent Diagnostic Testing Facility, also referred to as freestanding imaging centers.

MedPAC - Medicare Payment Advisory Commission. MedPAC reviews and analyzes data on healthcare services and payments and makes recommendations to CMS and Congress on improving Medicare programs. (www.medpac.gov)

MIRODA - Medical Imaging and Radiation Oncology Data Alliance. The Medical Imaging and Radiation Oncology Data Alliance (MIRODA) is a consortium of organizations representing professionals performing medical imaging and radiation oncology. The mission of MIRODA is to collect, analyze, report, and disseminate data on the medical imaging and radiation oncology professions. (www.miroda.org)

NDC – National Drug Code (expressed as a number). Codes that are maintained and distributed by the United States Food and Drug Administration, in collaboration with drug manufacturers, are to be used to report drugs and biologics.

NIH - National Institutes of Health. The NIH is the world’s premier medical research organization with institutes involved in intramural and extramural research on diseases like cancer, heart ailments, and AIDS. Nuclear Medicine research is integral to many of the projects funded through the NIH. (www.nih.gov)

NMIA - Nuclear Medicine Imaging Association of North America. The NMIA is an organization of Nuclear Medicine industry representatives interested in education and outreach issues regarding the practice of Nuclear Medicine.

NRC - Nuclear Regulatory Commission. The NRC is an independent agency established to ensure adequate protection of public health and safety and of the environment from the use of nuclear materials in the United States. For Nuclear Medicine departments, the NRC has regulatory control over medical uses of nuclear materials and the transport, storage, and disposal of nuclear materials and waste. Nuclear Medicine facilities are inspected by representatives of the NRC to determine compliance with the NRC regulations. (www.nrc.gov)

OSHA - Occupational Safety and Health Administration. OSHA requires employers to follow national standards of operation. The work area must meet certain requirements to be considered safe. Nuclear Medicine departments must meet these safety standards or the departments are fined or closed until they are compliant. (www.osha-slc.gov)

PFS – Physician Fee Schedule. This term is commonly used when referring to the Medicare Physician Fee Schedule (MPFS).

PRO - Peer Review Organization. CMS has recently renamed this organization the Quality Improvement Organization (QIO).

QIO - Quality Improvement Organization. (formerly called Utilization and Quality Control Peer Review Organization (PRO). QIO is a medical review organization under contract with the US Department of Health and Human Services to review the appropriateness of settings of care and the quality of care provided to Medicare beneficiaries.

RBRVS - Resource-Based Relative Value Scale. A method of reimbursement under Medicare that attempts to base physician reimbursement on the amount of resources, including cognitive and evaluative skills, required to diagnose and treat conditions. The approach weighs resources, such as practice costs and the cost of specialty training, that are an integral part of the performance of a service or procedure.

SNM - Society of Nuclear Medicine. An international scientific and professional organization founded in 1954 to promote the science, technology, and practical application of Nuclear Medicine. Its members are physicians, technologists, and scientists specializing in the research and practice of Nuclear Medicine. (www.snm.org)

USP - United States Pharmacopeia. A private, voluntary, not-for-profit, healthcare organization of professionals, scientists, academicians, and government officials who are responsible for the ongoing revision and development of the United States Pharmacopeia and the National Formulary. (www.usp.org)

USP-DI - The USP-Dispensing Information. A compilation of information on accepted uses of listed drugs. Listing in USP-DI meets the Medicare statutory criteria for drugs and biologicals.

Reimbursement Hotline

1 800 767 6664
Toll-free Monday - Friday
9:00 am to 4:00 pm

1 877 639 2796
Brachytherapy except high activity sources
Menu option 4