Low Osmolar Contrast Media Changes 2005
Coding Changes
Effective April 1, 2005, reporting the use of low osmolar contrast media (LOCM) changed for Medicare patients in the noninstitutional setting (Pub. 100-04 Medicare Claims Processing, Transmittal 502, CR 3748). Prior to April 1, 2005 LOCM was reported with HCPCS Level II "A" codes: A4644 (LOCM 100-199 mgs iodine), A4645 (LOCM 200-299 mgs iodine, A4646 (LOCM 300-399 mgs iodine). These "A" codes have been replaced with 7 new HCPCS Level II "Q" codes (Q9945-Q9951) for all Medicare patients except those in the hospital outpatient setting. The new "Q" codes more accurately describe the amount of contrast media used, the route by which it is administered, and the type of contrast media used during the scan.
In addition, codes A4643 and A4647, which formerly described the use of MR contrast materials, have been replaced with "Q" codes (Q9952, Q9953, Q9954) for all Medicare patients except those in the hospital outpatient setting.
Since HCPCS Level II "A" codes remain active for the reporting of LOCM, third-party payers may elect to continue their use. Check with your third- party payers for their guidelines and the codes they recommend for the reporting of contrast media, i.e., "A" vs. "Q" codes.
See table below for a list of the new HCPCS Level II "Q" codes. For a copy of the CMS transmittal on the LOCM codes go to the CMS Web site at www.cms.hhs.gov/manuals/pm_trans/R502CP.pdf .
Removal of LOCM Restrictive Criteria
The Centers for Medicare and Medicaid Services (CMS) has eliminated the restrictive criteria for reimbursement of LOCM, effective April 1, 2005 (Federal Register, November 15, 2004, Vol. 69, No. 219, p.66356-66357). In the past, CMS had paid for high osmolar contrast media (bundled into the procedure code) under all circumstances, but reimbursed for LOCM (non-ionic contrast) only if the patient met 1 of 5 criteria outlined by CMS: history of previous adverse reaction to contrast, history of asthma or allergy, significant cardiac dysfunction, generalized severe debilitation, and sickle cell disease.
The criteria previously used by CMS were quite restrictive and sometimes costly to determine. The ACR recommended in a March 15, 2004 letter to CMS that LOCM be reimbursable in all instances when it was medically necessary. With LOCM, patient risk and side effects are lower, as are the overall costs to the health care system. LOCM, with its lower incidence of side effects, also eliminates the need for a repeat procedure. After deliberation of the recommendations by the ACR, CMS lifted the restrictive criteria effective April 1, 2005.
Payment for contrast media will be based on the average sales price plus 6% (Transmittal 502, CR 3748), according to the standard drug pricing established by the Medicare Modernization Act. This means that the contrast manufactures will need to report their prices on contrast products, which will then be incorporated into setting average prices for the new "Q" codes.
Reference the table below for a listing of the average sales price as of April 1, 2005.
Table of New HCPCS "Q" codes and ASP pricing
| Q9945 | LOCM< =149 mg/ml iodine, 1ml | 1ml | $0.496 |
| Q9946 | LOCM 150-199 mg/ml iodine, 1ml | 1ml | $1.959 |
| Q9947 | LOCM 200-249 mg/ml iodine, 1ml | 1ml | $0.772 |
| Q9948 | LOCM 250-299 mg/ml iodine, 1ml | 1ml | $0.650 |
| Q9949 | LOCM 300-349 mg/ml iodine, 1ml | 1ml | $0.397 |
| Q9950 | LOCM 350-399 mg/ml iodine, 1ml | 1ml | $0.262 |
| Q9951 | LOCM > = 400 mg/ml iodine, 1ml | 1ml | * |
| Q9952 | Inj. Gad-based MR contrast, ml | 1ml | $2.957 |
| Q9953 | Inj. Fe-based MR contrast, ml | 1ml | * |
| Q9954 | Oral MR contrast, 100 ml | 100ml | $0.088 |
*Information on pricing for Q9951 and Q9953 not available from CMS.
Note: Some Medicare carriers have implemented the use of the new "Q" codes, but have not lifted the restrictive criteria. The ACR is working with the national office to ensure that all carriers remove the restrictive criteria as instructed in the Medicare Physician Fee Schedule Final Rule 2005.