CMS Pub. 100-04, ch. 13, § 30.1.3

Low Osmolar Contrast Material (LOCM) (Radiology)

(Rev. 1, 10-01-03)

When a radiology procedure is provided with contrast material, a SNF should bill using the CPT-4 code

that indicates “with” contrast material. If the coding does not distinguish between “with” and “without”

contrast material, the SNF should use the available code.

Contrast material other than LOCM may be billed separately in addition to the radiology procedure, or it

may be billed as part of the amount for the radiology procedure. If the SNF bills separately for the

contrast material and the charge for the procedure includes a charge for contrast material, the SNF must

adjust the charge for the procedure to exclude any amount for the contrast material. Regardless of the

billing method used, charges are subject to the fee schedule.

When billing separately for this contrast material, the SNF should use revenue code 0255 (drugs incident

to radiology and subject to the payment limit) and report the charge on the same bill as the radiology

procedure. The A/B MAC (A) will not accept late charge bills for this service.

30.1.3.1 - A/B MAC (A) Payment for Low Osmolar Contrast Material (LOCM)

(Radiology)

(Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11,

2013, ICD-10: Upon Implementation of ICD-10

Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission

Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7,

2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS,

MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)

The LOCM is paid on a reasonable cost basis when rendered by a SNF to its Part B patients (in addition

to payment for the radiology procedure) when it is used in one of the situations listed below.

The following HCPCS are used when billing for LOCM.

HCPCS Code Description (January 1. 1994, and later)

A4644 Supply of low osmolar contrast material (100-199 mgs of iodine);

A4645 Supply of low osmolar contrast material (200-299 mgs of iodine); or

A4646 Supply of low osmolar contrast material (300-399 mgs of iodine).

When billing for LOCM, SNFs use revenue code 0636. If the SNF charge for the radiology procedure

includes a charge for contrast material, the SNF must adjust the charge for the radiology procedure to

exclude any amount for the contrast material.

NOTE: LOCM is never billed with revenue code 0255 or as part of the radiology procedure.

The A/B MAC (A) will edit for the intrathecal procedure codes and the following codes to determine if

payment for LOCM is to be made. If an intrathecal procedure code is not present, or one of the ICD

codes is not present to indicate that a required medical condition is met, the A/B MAC (A) will deny

payment for LOCM. In these instances, LOCM is not covered and should not be billed to Medicare.

When LOCM Is Separately Billable and Related Coding Requirements

• In all intrathecal injections. HCPCS codes that indicate intrathecal injections are:

70010 70015 72240 72255 72265 72270 72285 72295

One of these must be included on the claim; or

• In intravenous and intra-arterial injections only when certain medical conditions are present in an

outpatient. The SNF must verify the existence of at least one of the following medical

conditions, and report the applicable diagnosis code(s) either as a principal diagnosis code or

other diagnosis codes on the claim:

o A history of previous adverse reaction to contrast material. The applicable ICD-9-CM codes

are V14.8 and V14.9. The applicable ICD-10-CM codes are Z88.8 and Z88.9. The

conditions which should not be considered adverse reactions are a sensation of heat, flushing,

or a single episode of nausea or vomiting. If the adverse reaction occurs on that visit with the

induction of contrast material, codes describing hives, urticaria, etc. should also be present, as

well as a code describing the external cause of injury and poisoning, ICD-9-CM code E947.8.

The applicable ICD-10 CM codes are: T50.8X5A Adverse effect of diagnostic agents, initial

encounter, T50.8X5S Adverse effect of diagnostic agents, sequela , T50.995A Adverse effect

of other drugs, medicaments and biological substances, initial encounter, or T50.995S

Adverse effect of other drugs, medicaments and biological substances, sequela;

o A history or condition of asthma or allergy. The applicable ICD-9-CM codes are V07.1,

V14.0 through V14.9, V15.0, 493.00, 493.01, 493.10, 493.11, 493.20, 493.21, 493.90,

493.91, 495.0, 495.1, 495.2, 495.3, 495.4, 495.5, 495.6, 495.7, 495.8, 495.9, 995.0, 995.1,

995.2, and 995.3. The applicable ICD-10-CM codes are in the table below:

ICD-10-CM Codes

J44.0 J44.9 J45.20 J45.22 J45.30 J45.32 J45.40

J45.42 J45.50 J45.52 J45.902 J45.909 J45.998 J67.0

J67.1 JJ67.2 J67.3 J67.4 J67.5 J67.6 J67.7

J67.8 J67.9 J96.00 J96.01 J96.02 J96.90 J96.91

J96.92 T36.0X5A T36.1X5A T36.2X5A T36.3X5A T36.4X5A T36.5X5A

T36. 6X5A T36.7X5A T36.8X5A T36.95XA T37.0X5A T37.1X5A T37.2X5A

T37.3X5A T37.8X5A T37.95XA T38.0X5A T38.1X5A T38.2X5A T38.3X5A

T38.4X5A T38.6X5A T38.7X5A T38.805A T38.815A T38.895A T38.905A

T38.995A T39.015A T39.095A T39.1X5A T39.2X5A T39.2X5A T39.315A

T39.395A T39.4X5A T39.8X5A T39.95XA T40.0X5A T40.1X5A T40.2X5A

T40.3X5A T40.4X5A T40.5X5A T40.605A T40.695A T40.7X5A T40.8X5A

T40.905A T40.995A T41.0X5A T41.1X5A T41.205A T41.295A T41.3X5A

T41.4X5A T41.X5A T41.5X5A T42.0X5A T42.1X5A T42.2X5A T42.3X5A

T42.4X5A T42.5X5A T42.6X5A 427.5XA 428.X5A T43.015A T43.025A

T43.1X5A T43.205A T43.215A T43.225A T43.295A T43.3X5A T43.4X5A

T43.505A T43.595A T43.605A T43.615A T43.625A T43.635A T43.695A

T43.8X5A T43.95XA T44.0X5A T44.1X5A T44.2X5A T44.3X5A T44.6X5A

T44.7X5A T44.8X5A T44.905A T44.995A T45.0X5A T45.1X5A T45.2X5A

T45.3X5A T45.4X5A T45.515A T45.525A T45.605A T45.615A T45.625A

T45.695A T45.7X5A T45.8X5A T45.95XA T46.0X5A T46.1X5A T46.2X5A

T46.3X5A T46.4X5A T46.5X5A T46.6X5A T46.7X5A T46.8X5A T46.905A

T46.995A T47.0X5A T47.1X5A T47.2X5A T47.3X5A T47.4X5A T47.5X5A

T47.6X5A T47.7X5A T47.8X5A T47.95XA T48.0X5A T48.1X5A T48.205A

T48.295A T48.3X5A T48.4X5A T48.5X5A T48.6X5A T48.905A T48.995A

T49.0X5A T49.1X5A T49.2X5A T49.3X5A T49.4X5A T49.5X5A T49.6X5A

T49.6X5A T47.X5A9 T49.8X5A T49.95XA T50.0X5A T50.1X5A T50.2X5A

T50.3X5A T50.4X5A T50.5X5A T50.6X5A T50.7X5A T50.8X5A T50.905a

T50.995A T50.A15A T50.A25A T50.A95A T50.B15A T50.B95A T50.Z15A

T50.Z95A T78.2XXA T78.3XXA T78.40XA T78.41XA T88.52XA T88.59XA

T88.6XXA Z51.89 Z88.0 Z88.1 Z88.2 Z88.3 Z88.4

Z88.5 Z88.6 Z88.7 Z88.8 Z88.9 Z91.010

o Significant cardiac dysfunction including recent or imminent cardiac decompensation,

severe arrhythmia, unstable angina pectoris, recent myocardial infarction, and pulmonary

hypertension. The applicable ICD-9-CM codes are:

ICD-9-CM

402.00 402.01 402.10 402.11 402.90 402.91

404.00 404.01 404.02 404.03

404.10 404.11 404.12 404.13

404.90 404.91 404.92 404.93

410.00 410.01 410.02 410.10 410.11 410.12

410.20 410.21 410.22 410.30 410.31 410.32

ICD-9-CM

410.40 410.41 410.42 410.50 410.51 410.52

410.60 410.61 410.62 410.70 410.71 410.72

410.80 410.81 410.82 410.90 410.91 410.92

411.1 415.0 416.0 416.1 416.8 416.9

420.0 420.90 420.91 420.99 424.90 424.91

424.99 427.0 427.1 427.2 427.31 427.32

427.41 427.42 427.5 427.60 427.61 427.69

427.81 427.89 427.9 428.0 428.1 428.9 429.0

429.1 429.2 429.3 429.4 429.5 429.6 429.71

429.79 429.81 429.82 429.89 429.9 785.50 785.51 785.59

o The applicable ICD-10-CM codes are in the table below:

ICD-10-CM Codes

A18.84 I11.0 I11.9 I13.0 I13.10 I13.11 I13.2

I20.0 I21.01 I21.02 I21.09 I21.11 I21.19 I21.21

I21.29 I21.3 I21.4 I22.1 I22.2 I22.8 I23.0

I23.1 I23.2 I23.3 I23.4 I23.5 I23.6 I23.7

I23.8 I25.10 I25.110 I25.700 I25.710 I25.720 I25.730

I25.750 I25.760 I25.790 I26.01 I26.02 I26.09 I27.0

I27.1 I27.2 I27.81 I27.89 I27.9 I30.0 I30.1

I30.8 I30.9 I32 I38 I39 I46.2 I46.8

I46.9 I47.0 I471 I472 I47.9 I48.0 I48.1

I48.1 I48.2 I48.3 I48.4 I48.91 I48.92 I49.01

I49.02 I49.1 I49.2 I49.3 I49.40 I49.49 I49.5

I49.8 I49.9 I50.1 I50.20 I50.21 I50.22 I50.23

I50.30 I50.31 I50.32 I50.33 I50.40 I50.41 I50.42

I50.43 I50.9 I51 I51.0 I51.1 I51.2 I51.3

I51.4 I51.5 I51.7 I51.89 I51.9 I52 I97.0

I97.110 I97.111 I97.120 I97.121 I97.130 I97.131 I97.190

I97.191 M32.11 M32.12 R00.1 R57.0 R57.8 R57.9

o Generalized severe debilitation. The applicable ICD-9-CM codes are: 203.00, 203.01, all

codes for diabetes mellitus, 518.81, 585, 586, 799.3, 799.4, and V46.1. The applicable

ICD-10-CM codes are: J96.850, J96.00 through J96.02, J96.90 through J96.91, N18.1

through N19, R53.81, R64, and Z99.11 through Z99.12. Or

o Sickle Cell disease. The applicable ICD-9-CM codes are 282.4, 282.60, 282.61, 282.62,

282.63, and 282.69. The applicable ICD-10-CM codes are D56.0 through D56.3, D56.5

through D56.9, D57.00 through D57.1, D57.20, D57.411 through D57.419, and D57.811

through D57.819.

40 - Magnetic Resonance Imaging (MRI) Procedures

(Rev. 2307, Issued: 09-22-11, Effective: 07-07-11/02-24-11(CR 7296), Implementation: 09-26-11)

Effective September 28, 2009

The Centers for Medicare & Medicaid Services (CMS) finds that the non-coverage of magnetic

resonance imaging (MRI) for blood flow determination is no longer supported by the available evidence.

CMS is removing the phrase “blood flow measurement” and local Medicare contractors will have the

discretion to cover (or not cover).

Consult Publication (Pub.) 100-03, National Coverage Determinations (NCD) Manual, chapter 1, section

220.2, for specific coverage and non-coverage indications associated with MRI and MRA (Magnetic

Resonance Angiography).

Prior to January 1, 2007

A/B MACs (B) do not make additional payments for three or more MRI sequences. The relative value

units (RVUs) reflect payment levels for two sequences.

The technical component (TC) RVUs for MRI procedures that specify “with contrast” include payment

for paramagnetic contrast media. A/B MACs (B) do not make separate payment under code A4647.

A diagnostic technique has been developed under which an MRI of the brain or spine is first 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 MRI is performed with an additional

double dosage (0.2mmol/kg) of contrast material. When the high-dose contrast technique is utilized,

A/B MACs (B):

• Do not pay separately for the contrast material used in the second MRI procedure;

• Pay for the contrast material given for the third MRI procedure through supply code Q9952, the

replacement code for A4643, when billed with Current Procedural Terminology (CPT) codes

70553, 72156, 72157, and 72158;

• Do not pay for the third MRI procedure. For example, in the case of an MRI of the brain, if CPT

code 70553 (without contrast material, followed by with contrast material(s) and further

sequences) is billed, make no payment for CPT code 70551 (without contrast material(s)), the

additional procedure given for the purpose of administering the double dosage, furnished during

the same session. Medicare does not pay for the third procedure (as distinguished from the

contrast material) because the CPT definition of code 70553 includes all further sequences; and

• Do not apply the payment criteria for low osmolar contrast media in §30.1.2 to billings for code

Q9952, the replacement code for A4643.

Effective January 1, 2007

With the implementation for calendar year 2007 of a bottom-up methodology, which utilizes the direct

inputs to determine the practice expense (PE) relative value units (RVUs), the cost of the contrast media

is not included in the PE RVUs. Therefore, a separate payment for the contrast media used in various

imaging procedures is paid. In addition to the CPT code representing the imaging procedure, separately

bill the appropriate HCPCS “Q” code (Q9945 – Q9954; Q9958-Q9964) for the contrast medium utilized

in performing the service.

Effective February 24, 2011

Medicare will allow for coverage of MRI for beneficiaries with implanted PMs or cardioverter

defibrillators (ICDs) for use in an MRI environment in a Medicare-approved clinical study as described

in section 220.C.1 of the NCD manual.

Effective July 7, 2011

Medicare will allow for coverage of MRI for beneficiaries with implanted pacemakers (PMs) when the

PMs are used according to the Food and Drug Administration (FDA)-approved labeling for use in an

MRI environment as described in section 220.2.C.1 of the NCD Manual.