Notification



Notification Issue Date:



Claim Payment Policy


Title:Magnetic Resonance Imaging (MRI) Contrast Agents

Policy #:09.00.45h


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

The Company covers magnetic resonance imaging (MRI) contrast agents. However, the contrast agents are not eligible for reimbursement separate from the diagnostic or therapeutic procedure. The contrast agents 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, the following: 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

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

Magnetic resonance (MR) contrast agents, also known as contrast media, are diagnostic pharmaceutical compounds containing paramagnetic ions that affect MR signal properties of surrounding tissues. They are used to improve the visibility of internal body structures in magnetic resonance imaging. Gadolinium chelates are the most commonly utilized MR contrast agents. Other MR contrast agents are iron oxide contrast agents such as superparamagnetic iron oxide (SPIO), ultrasmall superparamagnetic iron oxide (USPIO), and superparamagnetic iron-platinum particles (SIPPs).
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). CMS Manual System. Transmittal 804. Pub 100-04: Medicare claims processing. [CMS Web site]. 01/03/06. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R804CP.pdf. Accessed August 12, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 13: Radiology Services and Other Diagnostic Procedures. [CMS Web site]. Revised 03/27/19. 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]. 03/28/13. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3847.pdf. Accessed August 12, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. 4250: January 2006 update of the hospital outpatient prospective payment system (OPPS): Summary of payment policy changes and OPPS PRICER logic changes. [CMS Web site]. 01/01/06. Revised 04/03/2013. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4250.pdf. Accessed August 12, 2019.


Coding

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

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)





Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)




HCPCS Level II Code Number(s)


A9575Injection, gadoterate meglumine, 0.1 ml
A9576Injection, gadoteridol, (ProHance multipack), per ml
A9577Injection, gadobenate dimeglumine (MultiHance), per ml
A9578Injection, gadobenate dimeglumine (MultiHance multipack), per ml
A9579Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml
A9581Injection, gadoxetate disodium, 1 ml
A9585Injection, gadobutrol, 0.1 ml
Q9953Injection, iron-based magnetic resonance contrast agent, per ml
Q9954Oral magnetic resonance contrast agent, per 100 ml


THE FOLLOWING CODE(S) IS/ARE USED TO REPRESENT NONRADIOACTIVE CONTRAST IMAGING MATERIAL, NOT OTHERWISE CLASSIFIED, PER STUDY:


A9698Nonradioactive contrast imaging material, not otherwise classified, per study



Revenue Code Number(s)




Coding and Billing Requirements


Cross References


Policy History

Revisions from 09.00.45h:
11/18/2019This version of the policy will become effective 11/18/2019. The policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetic Resonance Imaging (MRI) Contrast Agents. The following procedure code was added:

A9698 Nonradioactive contrast imaging material, not otherwise classified, per study

Revisions from 09.00.45g:
08/29/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetic Resonance Imaging (MRI) Contrast Agents.

Effective 10/05/2017, this policy has been updated to the new policy template format.
Version Effective Date: 11/18/2019
Version Issued Date: 11/18/2019
Version Reissued Date: N/A



2017 AmeriHealth.