Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Contrast Agents Used in Conjunction with Echocardiography
Policy #:MA09.004b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Contrast agents used in conjunction with covered diagnostic or therapeutic echocardiography procedures (e.g., perflexane, octafluoropropane, perflutren) are covered and eligible for reimbursement consideration by the Company when performed by a professional provider in the office setting.

Contrast agents used in conjunction with diagnostic or therapeutic echocardiography procedures administered in the facility setting are included in the claim payment for the procedure and, therefore, are not eligible for separate reimbursement.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

Contrast agents, also known as contrast media, are chemicals that enable visualization of tissues or organs by increasing contrast during echocardiography, radiography, or other imaging techniques. During echocardiography, utilizing contrast agents also enables the real-time assessment of intracardiac blood flow. During an echocardiographic procedure, as sound travels from one medium to another, changes in the density at the interface cause reflection of the sound waves. Greater differences in density result in a more echogenic interface and improved visualization. Gas-containing contrast agents routinely utilized as gas are 100,000 times less dense than blood.

The contrast agents used during echocardiography consist of microspheres of gas encased within a thin biocompatible shell composed of protein, lipid, or polymers. Their small size and durability allows the microspheres to remain within the vascular system and to flow through the pulmonary circulation to the systemic circulation following peripheral injections. There are currently three principally different agents available:
  • Air with a galactose and palmitic acid as a surfactant
  • Octafluoropropane within an albumin shell or lipid shell
  • Sulphur hexafluoride with a phospholipid shell

The gas contained within the microspheres diffuses through the shells within a half-life of a few minutes in blood, ultimately diffusing into the lungs during pulmonary circulation.
References

Andreas, Adam, Dixon, Adrain K., Gillard, Jonathan H., and Schaefer-Prokop, Cornelia M. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging. 6th edition. Elsevier Limited, 2015.

Brant MD, William E., Helms MD, Clyde A., Klein MD FACR, Jeffrey,Jennifer Pohl,Vinson MD, Emily N. Fundamentals of Diagnostic Radiology .5th edition. Philadelphia: Lippincott, Williams & Wilkins. 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing. Transmittals for Chapter 12, 30.4 - Cardiovascular System (Codes 92950-93799), A. Echocardiography Contrast Agents. [CMS Web site]. 07/25/19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed October 3, 2019.

New Contrast Agents Healthcare Common Procedure Coding System (HCPCS) Codes. MLN Matters. April 1, 2005. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM3748.pdf. Accessed October 3, 2019.

Novitas Solutions Local Coverage Determination (LCD). L35016: Transesophageal Echocardiography (TEE). Original Effective Date: 10/01/15. Revised: 04/25/19. [Novitas Solutions website]. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35016&ver=32&Date=10%2f03%2f2019&SearchType=Advanced&DocID=L35016&bc=KAAAABgAAAAA&. Accessed October 3, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



A9700 Supply of injectable contrast material for use in echocardiography, per study

Q9950 Injection, sulfur hexafluoride lipid microspheres, per ml

Q9955 Injection, perflexane lipid microspheres, per ml

Q9956 Injection, octafluoropropane microspheres, per ml

Q9957 Injection, perflutren lipid microspheres, per ml




Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

REVISIONS FROM MA09.004b
11/18/2019This version of the policy will become effective 11/18/2019. The policy has been reviewed and reissued to communicate the Company’s continuing position on Contrast Agents Used in Conjunction with Echocardiography.
________________________

On 03/05/2020 the Policy History section was revised. Code A9950 was mistakenly listed as having been removed from the policy. The reference to A9950 was removed and replaced by the correct reference to code Q9950:

The following procedure code was added to the policy:
Q9950 Injection, sulfur hexafluoride lipid microspheres, per ml

REVISIONS FROM MA09.004a
11/21/2018This policy became effective 12/30/2015. It has been reviewed and reissued to communicate the Company’s continuing position on echocardiography contrast agents.
12/30/2015This is a policy update.

MA0.004
01/01/2015This is a new policy.






Version Effective Date: 11/18/2019
Version Issued Date: 11/18/2019
Version Reissued Date: N/A