Notification



Notification Issue Date:



Claim Payment Policy


Title:High Osmolar Contrast Agents

Policy #:09.00.13c

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

The Company covers high osmolar contrast agents; however, the contrast agents are not eligible for separate reimbursement from the diagnostic or therapeutic procedure and are included in the claim payment for the procedure.

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: 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.
Guidelines


Description

High osmolar contrast agents, also known as contrast media, are chemicals that enable visualization of tissues or organs by enhancing density differences between lesions and surrounding tissue during radiography or other imaging techniques.

Iodine is the only element that is proven satisfactory for general use as an intravascular contrast medium for radiography. All iodinated contrast agents have a chemical structure that is based on a benzene ring containing three iodine atoms. High osmolar contrast media are acid salts that dissociate in water into an inodine-containing, negatively charged anion (i.e., diatrizoate, iothalamate), and a positively charged cation. The high osmolality and viscosity of these agents can cause significant hemodynamic, cardiac and subjective effects including vasodilatation, heat, pain, osmotic diauresis and decreased myocardial contractility.
References

Adam, Andy. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging. Sixth ed.


Brant, William E. Fundamentals of Diagnostic Radiology. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2007.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 600. Pub 100-04: Medicare claims processing. [CMS Web site]. 05/22/15. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3264CP.pdf. Accessed October 21, 2015.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual.Ch 13: Radiology services and other diagnostic procedures. [CMS Web site]. revised 04-13-2015 Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf Accessed October 21, 2015.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. 3847: New Healthcare Common Procedure Coding System (HCPCS) drug codes. [CMS Web site]. 03/28/2013. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3847.pdf. Accessed November 11, 2015.




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)

Q9958: High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml


Q9959: High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml

Q9960: High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml

Q9961: High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml

Q9962: High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml

Q9963: High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml

Q9964: High osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 12/30/2015
Version Issued Date: 12/30/2015
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.