Notification



Notification Issue Date:



Claim Payment Policy


Title:Magnetic Resonance Imaging (MRI) Contrast Agents

Policy #:09.00.45g

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

The Company covers magnetic resonance imaging (MRI) contrast agents. However, the contrast agents are not eligible for reimbursement separate from the diagnostic or therapeutic procedure. The contrast agents 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, 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.
Guidelines


Description

Magnetic resonance (MR) contrast agents, also known as contrast media, are diagnostic pharmaceutical compounds containing paramagnetic ions that affect MR signal properties of surrounding tissues. They are used to improve the visibility of internal body structures in magnetic resonance imaging. Gadolinium chelates are the most commonly utilized MR contrast agents. Other MR contrast agents are iron oxide contrast agents such as superparamagnetic iron oxide (SPIO), ultrasmall superparamagnetic iron oxide (USPIO), and superparamagnetic iron-platinum particles (SIPPs).
References


Adam A. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging. 6th ed. Philadelphia: Elsevier. 2015.

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

Centers for Medicare & Medicaid Services (CMS). Ch II: Coverage issues appendix. Part 50: Diagnostic services. [CMS Web site]. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c02.pdf. Accessed June 14, 2018.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 804. Pub 100-04: Medicare claims processing. [CMS Web site]. 01/03/06. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R804CP.pdf. Accessed June 14, 2018.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. #4250: January 2006 update of the hospital outpatient prospective payment system (OPPS): Summary of payment policy changes and OPPS PRICER logic changes. [CMS Web site]. 01/01/06. Revised: 04/03/2013 Available at:http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4250.pdf. Accessed June 14, 2018.

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 June 14, 2018.

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 June 14, 2018.




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)



A9575 Injection, gadoterate, meglumine, 0.1 ml

A9576 Injection, gadoteridol, (prohance multipack), per ml

A9577 Injection, gadobenate dimeglumine (multihance), per ml

A9578 Injection, gadobenate dimeglumine (multihance multipack), per ml

A9579 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified

A9581 Injection, gadoxetate disodium, 1ml

A9585 Injection, gadobutrol, 0.1ml

Q9953 Injection, iron-based magnetic resonance contrast agent, per ml

Q9954 Oral magnetic resonance contrast agent, per 100 ml


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 09.00.45g:
08/29/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetic Resonance Imaging (MRI) Contrast Agents.


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: 08/29/2018

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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.