Payment for Low Osmolar Contrast Material (LOCM) (Radiology)

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 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.