Notification



Notification Issue Date:



Claim Payment Policy


Title:Low Osmolar Contrast Agents

Policy #:09.00.31d

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.

Low osmolar contrast agents are covered and eligible for reimbursement consideration by the Company when used in conjunction with a covered diagnostic or therapeutic procedure performed by a professional provider in the office setting.

Low osmolar contrast agents administered in the facility setting 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

Low 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 has 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. Reductions in osmolality, in comparison to high osmolar contrast agents, are achieved by making compounds that are nonionic monomers (i.e., iopamidol, iohexol, iversol), nonionic dimers (i.e., iodixanol, ioxilan), or monoacidic dimers (i.e., ioxaglate). Iodixanol is iso-osmolar. Low osmolar contrast agents have been used in radiological diagnosis studies when the use of other contrast material could be detrimental to an individual's health (e.g., a history of adverse reactions to contrast material; a history of asthma or allergy; significant cardiac dysfunction; generalized severe debilitation; or sickle cell disease). Low osmolar contrast agents, which include iso-osmolar agents, have a lower risk of adverse reaction than high osmolar contrast agents.
References

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


Barrs T. Establishing safeguards for the use of imaging-related drugs. Am J Health Syst Pharm. 2002;59(15):1449-1453. Also available on the Pub Med Web site at: http://www.medscape.com/viewarticle/442004_print. Accessed October 21, 2015.

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

Centers for Medicare & Medicaid Services (CMS). 2 CFR parts 410, 411, 412, et al. Medicare and Medicaid programs; interim and final rule. Part III: (196). 4 [CMS Web site]. 11/27/07. Available at: http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms1392fc.pdf. Accessed October 21, 2015.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Transmittal 502. Pub. 100-04: Medicare claims processing: New contrast agents Healthcare Common Procedure Coding System (HCPCS) codes. [CMS Web site]. 01/13/2012. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2386CP.pdf Accessed October 21, 2015

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 804. Pub 100-04: Medicare claims processing.Revision 3280- 06-15-2015 update of the hospital outpatient prospective payment system (OPPS): Summary of payment policy changes, OPPS PRICER logic changes, and instructions for updating the outpatient provider specific file (OPSF). [CMS Web site]. 06-15-2015 Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c04.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.

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 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)

Q9951 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml


Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml

Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml

Q9967 Low osmolar contrast material, 300-399 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.