MA PPO

Low Osmolar Contrast Agents
MA09.008a


Policy

Low osmolar contrast agents are covered and eligible for reimbursement consideration by the Company when used in conjunction with a covered diagnostic or therapeutic procedure performed by a professional provider in the office setting.

Low osmolar contrast agents administered in the facility setting 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


Low 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 has 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. Reductions in osmolality, in comparison to high osmolar contrast agents, are achieved by making compounds that are nonionic monomers (i.e., iopamidol, iohexol, iversol), nonionic dimers (i.e., iodixanol, ioxilan), or monoacidic dimers (i.e., ioxaglate). Iodixanol is iso-osmolar. Low osmolar contrast agents have been used in radiological diagnosis studies when the use of other contrast material could be detrimental to an individual's health (e.g., a history of adverse reactions to contrast material; a history of asthma or allergy; significant cardiac dysfunction; generalized severe debilitation; or sickle cell disease). Low osmolar contrast agents, which include iso-osmolar agents, have a lower risk of adverse reaction than high osmolar contrast agents.

References

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

Barrs T. Establishing safeguards for the use of imaging-related drugs. American Journal of Health-System Pharmacy. 2002;59(15):1449-1453. Available at: http://www.medscape.com/viewarticle/442004. Accessed August 15, 2019.

Brant M.D., William E, Helms M.D., Clyde A., Klein M.D. FACR, Jeffrey, Vinson M.D., Emily N. Fundamentals of Diagnostic Radiology, Fifth edition. Philadelphia: LWW; Lippincott, Williams & Wilkins, 2018.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 502. Pub. 100-04: Medicare claims processing: New contrast agents Healthcare Common Procedure Coding System (HCPCS) codes. [CMS Web site]. 01/13/2012. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2386CP.pdf. Accessed August 15, 2019.

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 15, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matter. 3748: New Contrast Agents Healthcare Common Procedure Coding System (HCPCS) Codes. [CMS Web site]. 04/01/2005. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM3748.pdf. Accessed August 15, 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)
Q9951 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml

Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml

Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml

Q9967 Low osmolar contrast material, 300-399 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
MA09.008
Claim Payment Policy Bulletin
Medicare Advantage
Yes