Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

High Osmolar Contrast Agents

Policy #:

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)

Q9958	High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml
Q9959	High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml
Q9960	High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml
Q9961	High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml
Q9962	High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml
Q9963	High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml
Q9964	High osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA09.005a:

03/24/2021	The policy has been reviewed and reissued to communicate the Company’s continuing position on High Osmolar Contrast Agents.
10/09/2019	This policy has been reviewed and reissued to communicate the Company’s continuing position on High Osmolar Contrast Agents.
12/30/2015	This is a policy update.

Revisions From MA09.005:

01/01/2015

This is a new policy.

Effective 10/05/2017, the policy has been updated to the new policy template format.

Version Effective Date:

12/30/2015

Version Issued Date: