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Magnetic Resonance Imaging (MRI) Contrast Agents
09.00.45k

Policy

The Company covers magnetic resonance imaging (MRI) contrast agents; however, the they are not eligible for ​separate reimbursement from the diagnostic or therapeutic procedure ​and are included in the reimbursement for the ​associated procedure. Participating providers may not bill members for this service.​

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, and therapies, as well as 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, Andy. Grainger & Allison's Diagnostic Radiology, 2-Volume Set: A Textbook of Medical Imaging. Sixth edition.

Brant MD, William E, Helms MD, Clyde A., Klein MD FACR, Jeffrey, Vinson MD, Emily N. Fundamentals of Diagnostic Radiology, Fifth edition. Philadelphia: LWW; Lippincott, Williams & Wilkins, 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 February 9, 2021.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 13: Radiology Services and Other Diagnostic Procedures. [CMS Web site]. Revised 03/27/19. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf. February 9, 2021.

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
A9573Injection, gadopiclenol, 1 ml​
A9575
Injection, gadoterate meglumine, 0.1 ml
A9576Injection, gadoteridol, (ProHance multipack), per ml
A9577Injection, gadobenate dimeglumine (MultiHance), per ml
A9578Injection, gadobenate dimeglumine (MultiHance multipack), per ml
A9579Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml
A9581Injection, gado​xetate disodium, 1 ml
A9585Injection, gadobutrol, 0.1 ml
​A9697​Injection, carboxydextran-coated superparamagnetic iron oxide, per study dose
​C9150​Xenon xe-129 hyperpolarized gas, diagnostic, per study dose​
Q9953Injection, iron-based magnetic resonance contrast agent, per ml
Q9954Oral magnetic resonance contrast agent, per 100 ml

THE FOLLOWING CODE IS USED TO REPRESENT NONRADIOACTIVE CONTRAST IMAGING MATERIAL, NOT OTHERWISE CLASSIFIED, PER STUDY:
A9698Nonradioactive contrast imaging material, not otherwise classified, per study​

Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From 09.00.45k:
10/01/2023This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2023.

HCPCS codes A9573 and A9697​ has been added to the policy.

Revisions From 09.00.45j:
07/01/2023This policy has been identified and updated for the CPT/HCPCS code update effective 7/01/2023.

HCPCS code C9150​ has been added to the policy.​

Revisions From 09.00.45i:
03/08/2023The policy has been reviewed and reissued to communicate the Company’s continuing position on​ magnetic resonance imaging (MRI) contrast agents.​
04/12/2021The policy has been reviewed and reissued to communicate the Company’s continuing position on​ magnetic resonance imaging (MRI) contrast agents.

Revisions From 09.00.45h:
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 Magnetic Resonance Imaging (MRI) Contrast Agents. The following procedure code was added:

A9698 Nonradioactive contrast imaging material, not otherwise classified, per study

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.
10/1/2023
10/24/2023
09.00.45
Claim Payment Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.