December 31, 2005

ACR Radiology Coding Source™ November-December 2005 Q and A

Q: How do you code for low osmolar contrast media (LOCM), high osmolar contrast media (HOCM), and paramagnetic contrast agents (i.e., gadolinium)?

A: Low Osmolar Contrast Media and High Osmolar Contrast Media

Effective January 1, 2006, Low osmolar contrast media (LOCM ) should be coded by using Q9945-Q9951 and High Osmolar Contrast Media (HOCM) should be coded by using Q9958-Q9964, respectively, in hospital and free-standing settings. Based on the 2006 Medicare Physician Fee Schedule (MPFS) Final Rule, separate payment for HOCM given in a free-standing setting will be delayed until a time when direct practice expense collected through the Practice Expense Advisory Committee can be used to determine the practice expense values in the MPFS. However, LOCM and HOCM are reimbursed separately in the hospital setting, as per the 2006 Hospital Outpatient Prospective Payment System (HOPPS) Final Rule, with the exception of HOCM code Q9959. CMS announced that they are packaging this code under HOPPS as they did not have sufficient pricing data available at this time. If Average Sales Price (ASP) data become available for this code, then CMS will reimburse separately based on the appropriate payment rate.

Over the last year, there have been numerous changes in coding and coverage that included the following:

  1. Elimination of the restrictive criteria for payment of LOCM (January 1, 2005), allowing payment of LOCM for all patients;
  2. Establishment of HOCM HCPCS Level II "Q" codes for tracking purposes without separate payment in the non-hospital setting (July 1, 2005); and
  3. Changes in payment for HOCM on the hospital outpatient side as of January 1, 2006.

Gadolinium:

Coding for paramagnetic contrast agents,ie, gadolinium, have changed and, similar to LOCM and HOCM, new "Q" codes have been established and implemented in the hospital and free-standing settings. Effective January 1, 2006, codes Q9952-Q9954 should be used for gadolinium in all settings. In the free-standing setting, gadolinium is not separately payable. CMS specifies that gadolinium is generally bundled into the MRI procedures because the TC RVUs for MRI procedures that specify "with contrast" include payment for paramagnetic contrast media. Medicare carriers may pay for the contrast material given for the third MRI procedure through the respective supplies code but understand that this example is rare.

Specifically, when an MRI of the brain or spine is performed without contrast material, then another MRI is performed with a standard (0.1mmol/kg) dose of contrast material, and based on the need to achieve a better image, a third MR is performed with an additional double dosage (0.2mmol/kg) of contrast material, the contrast should be reimbursed for that third MRI procedure. If you are being denied for gadolinium given under these rare circumstances, please contact your local Medicare carrier.

Note: According to officials at the national CMS office, the gadolinium codes Q9952-Q9954 are paid under the 2006 MPFS as described above (ie, third MRI) and separately payable under HOPPS Final Rule. CMS is planning to correct an error within the 2006 MPFS Final Rule, Addendum H that incorrectly identifies these Q codes being effective on January 1, 2007.

Use this link to  identify the codes to use and when to expect payment for the use of LOCM, HOCM and MR contrast agents under Medicare. (Note that separate payment of supplies by other third party payers is based on individual contracts.)

 

References:

Retroactive Payment for LOCM, ACR Radiology Coding SourceTM, Sept/Oct 2005

CMS Publishes Transmittal Removing LOCM Restrictive Coverage Criteria, ACR Radiology Coding SourceTM, Jul/Aug 2005

ACR Presses CMS to Update Low Osmolar Contrast Material Coverage;
New HCPCS Codes for HOCM Tracking, ACR Radiology Coding SourceTM, May/June 2005

Payment for Low Osmolar Contrast Media (Transmittal 627)

Payment Conditions for Radiology Services: Technical Component Payment of Magnetic Resonance Imaging Procedures, 15022(B)(6)

Radiology Services: CMS Manual System, Pub 100-4 Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 13, Section 40

Q: Is an order from the referring physician required for 3D rendering procedures in the non-hospital setting?

A: In the past, the ACR maintained that an order for 2D and 3D reconstruction imaging was not necessary as this was covered under the Ordering of Diagnostic Tests rule test design exception. However, based on the exponential rise in the use of 76375 and in the number of practice investigations evolving out of overutilization (routine use), the ACR strongly encourages radiology practices to obtain an order from the referring physician in the nonhospital setting. In the hospital setting, radiologists may generate their own order, but they are strongly encouraged to justify medical necessity for the use of 3D rendering in a separate dictation.

The 3D rendering should be done at the request of or in consultation with the referring physician when there is medical necessity. Referring physicians should be educated as to the need for an order and when 3D rendering would be beneficial. The 3D codes should be reserved for situations where additional imaging is necessary for surgical planning or for complete depiction of an abnormality from the two-dimensional study. Those practices that routinely provide 3D rendering may prompt an investigation by the Office of the Inspector General.