CEUS: Billing, Reimbursement and CPT Codes - HD

Current State of Billing and Reimbursement for Contrast Enhanced Ultrasound Studies

This presentation discusses the current state of billing
and reimbursement for contrast enhanced ultrasound studies.

FDA Approvals for Ultrasound Contrast Agents

Ultrasound contrast agents are currently approved
for intravenous administration by the FDA.
These are Luson by BRCA Diagnostics,
Definit by Lantus Medical Imaging
and Optisan by GE Medical.
The three agents are approved
for left ventricular opacification in echocardiography
in March of 2016.
The FDA approved LUMON contrast enhanced ultrasound
for characterization of focal liver lesions.
This was the first application approved by the FDA
for contrast enhanced ultrasound outside the heart
in December of 2016.
Approval was extended to contrast ultrasound voiding cysto
urography for diagnosis of viter reflux in children.

Obtaining CPT Codes for Reimbursement

Obtaining current procedural terminology or CPT codes
for contrast ultrasound is a
prerequisite for reimbursement.
Requests for new CPT codes first have to be approved
by the CPT editorial panel
of the American Medical Association.
The codes are then issued
and valued by the relative value update committee
of the American Medical Association.
This body is composed of 31 members, 21 appointed
by major National Medical Society Specialists.
Following FDA approval, the American College
of Radiology set up a working group to begin the process
of getting CPT codes.
This group has submitted proposals
for contrast ultrasound CPT codes to the A-M-A-C-P-T panel
and the relative value update committee.
The process of obtaining CPT codes can take up to two years.
In the meantime, there are a number of transitional codes
that can be used for reimbursement
until CPT codes are available.
These codes are the Q code, Q 99, 50
C code, C 97 44,
and the intravenous injection code 96 37 4.
This presentation will explain these codes
and their applications.

Transitional Codes

Q Codes

What is a Q code?
A Q code is designed by CMS procedures, services,
and supplies on a temporary basis.
When a permanent code is assigned, the Q code is deleted
and cross-referenced.
The Q code is a transitional contrast agent code
and there are specific codes for each.
Contrast agent.
The code for lumon is Q 99 50.
The code for FIN is Q 99 57,
and that for Optisan is Q 99 56.
The codes became effective January 1st, 2017.
These are healthcare common procedure coding system
or H-C-P-C-S pass through codes.

Pass Through Codes

What is a pass through code?
A pass through code is a CMS vehicle to reimburse
for innovative drugs.
It is a temporary code that is valid until December the 31st
of 2017,
but is expected to be extended through September of 2018.
A vial of lumon contains 25 milligrams
of a lyophilized powder that is reconstituted with five mls
of normal saline.
Each Q 99 50 billing unit is one M.
Therefore, there are five billing units per mil.
The recommended dose for liver imaging is one
to 2.4 mils depending on patient's size,
so the entire vial is not used for most patients.
However, Q 99 50 can be billed for drug
that is reconstituted
but not administered by using the JW modifier.
For example, if out of a five mil vial,
two mils are administered
and three mils are discarded, this can be built as two units
of QQ 99 50
and three units of Q 99 50 dash jw.
The amount discarded should be documented in the patient's
medical record.
The date, time, and quantity wasted should be re recorded.
Some Medicare contractors have specific requirements
for documentation while others just note
that it should be documented.

C Codes

C code C 97 44
C 97 44 is a new technology,
healthcare common procedures coding system
or HC PS level one code.
What is a C code?
A C code is a code assigned by CMS for new technologies.
C 97 44 is described as ultrasound of abdomen with contrast.
BRCA applied for
and was approved for a C code on October the first, 2016.
This code is attached to an ambulatory payment
classification or a PC that provides a code
that describes the medical procedure
and assigns a payment value to reflect the new procedure.
It only applies
to hospital outpatient prospective payment system patients
and a pass through payment is payable to this code
injection code.

Injection Codes

What is an injection code?
An injection code is used to bill
for intravenous therapeutic prophylactic
or diagnostic injection of a single substance or drug.
It is only applicable if the place of service
is an independent diagnostic testing facility Under the
Medicare payment fee schedule.
The injection code is CPT 9 6 3 7 4.
It is not billable by physician
and it is not appropriate with modifier 26
or technical component.
Medicare often edits this code,
but commercial payers may accept it.
C 97 4 54 payment is linked under a PC
55 71
to a level one CPT imaging code with contrast.
In 2017, the A PC structure used in radiology,
echocardiography and cultural sound was consolidated.
The payment for level one imaging
with contrast under which C 97 44 falls is
designated as $265 and 2 cents.
Under the 2017 imaging restructuring,
the temporary codes only apply to the technical fee
CPT 76 700, the CPT code for ultrasound
of the complete abdomen and 7 6 7 0 5.
The CPT code for limited abdomen are used to bill
for the professional component.
There's currently no additional reimbursement
for the professional component
of contrast enhanced ultrasound
until CPT codes are available.

Reimbursement Details for Transitional Codes

Q 99 50.
The contrast agent code is a pass through code
and reimburses at $22 and 93 cents per mil
or $114
and 66 cents per vial at five mils per vi
9 6 3 7 4.
The intravenous injection code reimburses at $92
and 40 cents while C 9 7 44.
The new technology C code reimburses at $265
and 2 cents with a copayment of $47 and 38 cents.

Applications of the Transitional Codes

Applications of the transitional codes
C 97 44
and Q 99 50 can be used for Medicare outpatients.
Patients at physician owned imaging facilities
or independent diagnostic testing facilities can bill
Q 99 50 and 9 63 74,
but cannot bill C 9 70 44.
Inpatient payment is based on Medicare severity
diagnosis related groups or DGS that are based on diagnosis
and severity of illness.
As such, diagnostic tests not paid separately under DRGs.
However, bear in mind
that Lummis sun should always be reported in the patient
charge master as Q 99 50 per mil
in March, 2017, CMS extended,
C 97 44 to cover the use
of ultrasound contrast agents in the kidneys
and bladder, as well as the liver.

Commercial Payers

Commercial payers
to obtain reimbursement from commercial payers.
Ensure that Q 99 50 is in the commercial payer
contract database of your institution.
You need to establish a payment fee for all your contracts.
Some of your commercial payers may bundle the known contrast
with contrast, while others will separate them
on October 12th, 2017.
The A-M-A-C-P-T editorial panel meeting
accepted two new permanent CPT level one codes
for contrast enhanced ultrasound.

New Permanent CPT Codes

These codes are described as for reporting ultrasound
targeted dynamic microbubble sonographic
contrast characterization non-cardiac.
The new codes are seven six x zero x
for initial contrast injection
and seven six x one x for a subsequent injection
during the same study.
Thus, if multiple lesions are being evaluated
and each injection can be billed separately,
the X is a placeholder will be replaced
by a numeric value when the actual code is released.
The new codes are scheduled
to take effect on January the first 2019
RVU values for these codes are yet to be decided
and will be assigned at the next
relative value update committee meeting.
The RVU values will be based on surveys
of contrast ultrasound users.
The new codes are standalone codes,
meaning they can be performed independent
of other ultrasound codes.
They can be used for any organ
and are not limited to the liver, kidneys, or bladder.
They can be used for any contrast agent,
although at this time, lumon is the only contrast agent
approved by the FDA for non-cardiac applications.

Summary

In summary, temporary codes can be used
for contrast enhanced ultrasound reimbursement until
December the 31st, 2018.
For cardiac applications,
these temporary codes are Q 99, 50 C,
97, 44, and 9 6 3 7 4.
The pass through payment for Q 99 50 will sunset on
September the 30th, 2018.
While the other two codes are payable through the end
of 2018, the temporary codes only provide
for technical reimbursement.
These temporary codes can be used for imaging of the liver,
kidneys, and bladder.
After January the first 2019,
new CPT codes go into effect that will reimburse
for the professional and technical component
of a contrast enhanced ultrasound study.
These codes are seven six x zero x
and seven six x one x.
These codes are organ agnostic, agent agnostic,
and can be used on a per lesion basis.
The RVU value of these codes has not yet been decided.