Notification



Notification Issue Date:



Claim Payment Policy


Title:Echocardiography Contrast Agents

Policy #:09.00.11c

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.

Echocardiography contrast agents (e.g., perflexane, octafluoropropane, perflutren) 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.

Echocardiography 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, 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

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, William E. and Helms, Clyde. Fundamentals of Diagnostic Radiology .4th in four volumes edition. Philadelphia: Lippincott, Williams & Wilkins. 2012.

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]. 05/31/18. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed October 3, 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 October 3, 2018.

Novitas Solutions Local Coverage Determination (LCD). L35016: Transesophageal Echocardiography (TEE). Original Effective Date: 10/01/15. Revised: 10/01/17. [Novitas Solutions website]. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35016&ver=20&Date=10%2f03%2f2018&SearchType=Advanced&DocID=L35016&bc=KAAAABgAAAAA&. Accessed October 3, 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)



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

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


Cross References


Policy History

Revisions from 09.00.11c
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.


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: 11/21/2018

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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.