MA PPO

Contrast Agents Used in Conjunction with Echocardiography
MA09.004b


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 for the procedure and, therefore, are not eligible for separate reimbursement.

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.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

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, JeffreyJennifer PohlVinson 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 October 3, 2019.

New Contrast Agents Healthcare Common Procedure Coding System (HCPCS) Codes. MLN Matters. April 1, 2005. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM3748.pdf. Accessed October 3, 2019.

Novitas Solutions Local Coverage Determination (LCD). L35016: Transesophageal Echocardiography (TEE). Original Effective Date: 10/01/15. Revised: 04/25/19. [Novitas Solutions website]. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35016&ver=32&Date=10%2f03%2f2019&SearchType=Advanced&DocID=L35016&bc=KAAAABgAAAAA&. Accessed October 3, 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)

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


Coding and Billing Requirements



Policy History

11/18/2019
11/18/2019
MA09.004
Claim Payment Policy Bulletin
Medicare Advantage
Yes