MA PPO

High Osmolar Contrast Agents
MA09.005a


Policy

The Company covers high osmolar contrast agents. However, the contrast agents 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, 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 August 12, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. 3847: New Healthcare Common Procedure Coding System (HCPCS) drug codes. [CMS Web site]. 03/28/2013. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3847.pdf. Accessed August 12, 2019.

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


Coding and Billing Requirements



Policy History

12/30/2015
12/30/2015
10/9/2019
MA09.005
Claim Payment Policy Bulletin
Medicare Advantage
Yes