Medicare Advantage

Medical Policy

Notification

Contrast Agents Used in Conjunction with Echocardiography

Notification Issue Date:

This version of the policy will become effective 05/03/2021. The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits​.​​

Title:

Contrast Agents Used in Conjunction with Echocardiography

Policy #:

MA09.004c

Policy

Contrast agents used in conjunction with covered diagnostic or therapeutic echocardiography procedures (e.g., perflexane, octafluoropropane, perflutren) are covered and eligible for reimbursement consideration by the Company when performed by a professional provider in the office setting.

Contrast agents used in conjunction with diagnostic or therapeutic echocardiography procedures administered in the facility setting are included in the claim payment reimbursement for the associated procedure and, therefore, are not eligible for separate reimbursement. 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, 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

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

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 MD, William E., Helms MD, Clyde A., Klein MD FACR, Jeffrey, Jennifer Pohl, Vinson MD, Emily N. Fundamentals of Diagnostic Radiology .5th edition. Philadelphia: Lippincott, Williams & Wilkins. 2018.

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]. 07/25/19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed February 15, 2023.

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]. 07/25/19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed February, 15, 2023.

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)

A9700	Supply of injectable contrast material for use in echocardiography, per study
Q9950	Injection, sulfur hexafluoride lipid microspheres, per ml
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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA09.004c:

03/08/2023

The policy has been reviewed and reissued to communicate the Company’s continuing position on Contrast Agents Used in Conjunction with Echocardiography.

05/03/2021

This version of the policy will become effective 05/03/2021. The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits.

Revisions From MA09.004b:

11/18/2019

This 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 Contrast Agents Used in Conjunction with Echocardiography.
________________________

On 03/05/2020 the Policy History section was revised. Code A9950 was mistakenly listed as having been removed from the policy. The reference to A9950 was removed and replaced by the correct reference to code Q9950:

The following procedure code was added to the policy:
Q9950 Injection, sulfur hexafluoride lipid microspheres, per ml

Revisions From MA09.004a:

11/21/2018	This policy became effective 12/30/2015. It has been reviewed and reissued to communicate the Company’s continuing position on echocardiography contrast agents.
12/30/2015	This is a policy update.

Revisions From MA0.004:

01/01/2015

This is a new policy.

Version Effective Date:

5/3/2021

Version Issued Date:

5/3/2021

Version Reissued Date:

3/8/2023