Billing for Yttrium-90 (Y90) radioembolization procedures in an Office-Based Lab (OBL) is one of the most complex challenges in interventional radiology revenue cycle management. There is no one-size-fits-all answer. At StreamlineMD, we’ve worked closely with many OBL providers across the country who are facing significant hurdles when it comes to getting reimbursed for the radiopharmaceuticals used in these procedures.
This article’s objective is to help you navigate the maze of Y90 dose reimbursement in OBLs. It shares practical insights from the field, including billing strategies and documentation tips to help your practice overcome common denials and billing obstacles.
Why Is Y90 Dose Billing So Complicated in an OBL?
Y90 is a high-cost, complex procedure, and even a few denials can significantly impact cash flow. OBL owners must take a substantial risk by purchasing Y90 dose/spheres in advance, at roughly $18,000 per case.
Many commercial payers either don’t understand or reject Y90 dose codes billed on the CMS-1500 submitted by an OBL in place of service 11. They are often unfamiliar with such complex procedures being performed in place of service 11. This typically results in denials or underpayments, even with a valid prior authorization.
But the biggest challenge we observe in getting properly reimbursed for Y90 procedures in the OBL is to get insurance companies to properly reimburse the dose/sphere Q3001 codes that are included on these claims.
While Traditional Medicare and most Medicare Advantage plans recognize Q3001 as the proper code for the Y90 dose, reimbursement requirements vary. Some plans require invoices, others do not, so it’s essential to review policies for each MAC, Medicare Advantage, and commercial plan.
2025 CMS National Average Allowed Amounts for Typical Codes Billed for Y90 Cases
| CPT | CPT Description | CMS Allowed |
| 36247 | Selective catheter placement, arterial system | $1,310 |
| 36248 | Selective catheter placement, arterial system | $ 110 |
| 37243 | Vascular embolization or occlusion, | $ 7,842 |
| 75726 | Angiography, visceral, selective or supraselective | $ 166 |
| 75774 | Angiography, selective, each additional vessel studied | $ 93 |
| 76937 | Ultrasound guidance for vascular access | $ 37 |
| 77263 | Therapeutic radiology treatment planning; complex | $ 165 |
| 77300 | Basic radiation dosimetry calculation | $ 65 |
| 77470 | Special treatment procedure | $ 142 |
| 79445 | Radiopharmaceutical therapy | $ 105 |
| Q3001 | Radioelements for brachytherapy, any type, each* (Historical Est) | $ 18,450 |
| TOTAL | $ 28,485 |
Contracting the Dose Code
If your practice intends to perform Y90 procedures regularly in an OBL, the cleanest approach is to negotiate the dose code as a carve-out in your payer contracts. This ensures clarity and improves clean claim rates, although many will deny on first pass regardless.
Pre-Authorization & Code Strategy
Always obtain prior authorization for both the procedure and the dose code. Dose codes include:
- Q3001 – Radiopharmaceutical, therapeutic, per treatment (Fee for Service Medicare, some commercial / private payers including Medicare Advantage plans)
- S2095 – Transcatheter occlusion/embolization for tumor perfusion (includes guidance and imaging) (some commercial / private payers including Fee for Service Medicare and Medicare Advantage plans)
- C2616 – Brachytherapy source, yttrium-90, per source (some commercial / private payers)
During the authorization process, ask for benefit verification for each code. This can help ensure you’re aware of any exclusions tied to the patient’s specific policy and avoid using codes that are not reimbursable under that plan. Be aware that even prior authorization does not guarantee payment if the code is not on their fee schedule or excluded by your payer contract. Payment is also subject to the patient meeting the payer’s criteria for medical necessity and plan coverage.
Reimbursement Without a Contracted Rate
If the dose code isn’t contracted with a payer, you’ll need to:
- Review the payer’s fee schedule (either via portal access or by calling their provider line) to determine reimbursement allowances.
- Check the payer’s medical policy for Y90 or hepatic embolization, as coverage guidelines can vary significantly, by plan and even among state affiliates of the same national payer.
- Understand how the payer reimburses:
- Some reimburse based on invoice cost (submit itemized invoice with claim).
- Others pay per unit billed, requiring that claims reflect multiple units if applicable.
Documentation is Everything: Best Practices
Proper documentation is the cornerstone of successful Y90 billing and appeals. This cannot be emphasized enough. Your practice should:
- Keep physical/electronic copies of all authorization letters, screen shots throughout the authorization process, reference numbers, benefit verifications, and call recordings (where legal).
- Don’t rely on handwritten notes or simply enter the pre-auth number into your billing software.
- Request an authorization letter on payer letterhead if possible.
- Retain invoices for all supplies and radiopharmaceuticals
- Document clinical indications clearly in the patient’s record to support medical necessity
- Review payer-specific medical policies and include applicable citations in appeal letters
- Note if the payer excludes reimbursement in place of service 11 OBLs or requires hospital-based billing
- Make sure to include invoice price in box 19 of the CMS-1500 Claim form and submit the invoice if required
- Be sure to challenge Y90 dose/sphere vendors on billing rules and estimated reimbursements. We’ve learned from our clients that information from vendors and their representatives is often misleading and not reflective of actual payer requirements and reimbursements results.
Many denials can be overturned on appeal with the right supporting documentation. When you find patterns with certain payers, consider setting up payer-specific rules or edits in your billing software or clearinghouse to automate claim formatting and improve first-pass rates.
Closing Thoughts
There is no one-size-fits-all solution for billing Y90 radiopharmaceuticals in an OBL, but with proactive contracting, strong authorization workflows, payer-specific research, and complete documentation, your practice can reduce denials for this treatment. Compiling payer-specific guidelines and denial history can help refine your process and appeal strategies. Be prepared to appeal or re-bill with different codes and units. Once you have a carrier “figured out” you may consider setting up payer specific rules in your billing software or clearinghouse.
At StreamlineMD, we’re here to support you in navigating these payer challenges and maximizing your revenue cycle performance.
Resources:
- https://irq.sirweb.org/clinical-practice/SIRT-coding-guidance/#:~:text=If%20the%20IR%20physician%20is,the%20intraarterial%20therapeutic%20radiopharmaceutical%20injection)
- https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00231502
- https://www.bostonscientific.com/en-US/reimbursement/interventional-oncology.html#TheraSphere
- www.sirtex.com/Media/3g2hceis/Sirtex%20Coding%20Guide_OBL%20(HEPRA-US-002-02-24)3.pdf
StreamlineMD provides Revenue Cycle Solutions to Radiology & Interventional Specialists. Our Mission is to Improve Healthcare for All Americans. Our Core Values that guide us on our mission are Service Quality, Teamwork, Accountability, Efficiency, Adaptability, Communication, and Integrity. Proud winner of the Great Place To Work award. Learn more about us at streamlineMD.com.
