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High Osmolar Contrast Agents
MA09.005a

Policy

The Company covers high osmolar contrast agents; however, they are 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, 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

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

Description

High 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 is 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. High osmolar contrast media are acid salts that dissociate in water into an inodine-containing, negatively charged anion (i.e., diatrizoate, iothalamate), and a positively charged cation. The high osmolality and viscosity of these agents can cause significant hemodynamic, cardiac and subjective effects including vasodilatation, heat, pain, osmotic diauresis, and decreased myocardial contractility.

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). Medicare Claims Processing Manual. Chapter 13: Radiology Services and Other Diagnostic Procedures. [CMS Web site]. Revised 03-27-2019. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf. Accessed 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)
Q9958High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml
Q9959High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml
Q9960High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml
Q9961High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml
Q9962High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml
Q9963High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml
Q9964High osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml



Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

12/30/2015
12/30/2015
3/24/2021
MA09.005
Claim Payment Policy Bulletin
Medicare Advantage
No