-
Reimbursement Policy
CMS 1500 Policy Number 2020R0104A
Proprietary information of UnitedHealthcare Community Plan.
Copyright 2020 United HealthCare Services, Inc. 2020R0104A
Contrast and Radiopharmaceutical Materials Policy,
Professional
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are
responsible for submission of accurate claims. This reimbursement
policy is intended to ensure that you are reimbursed based on the
code or codes that correctly describe the health care services
provided. UnitedHealthcare Community Plan reimbursement policies
uses Current Procedural Terminology (CPT®*), Centers for Medicare
and Medicaid Services (CMS) or other coding guidelines. References
to CPT or other sources are for definitional purposes only and do
not imply any right to reimbursement. This reimbursement policy
applies to all health care services billed on CMS 1500 forms and,
when specified, to those billed on UB04 forms. Coding methodology,
industry-standard reimbursement logic, regulatory requirements,
benefits design and other factors are considered in developing
reimbursement policy. This information is intended to serve only as
a general reference resource regarding UnitedHealthcare Community
Plan’s reimbursement policy for the services described and is not
intended to address every aspect of a reimbursement situation.
Accordingly, UnitedHealthcare Community Plan may use reasonable
discretion in interpreting and applying this policy to health care
services provided in a particular case. Further, the policy does
not address all issues related to reimbursement for health care
services provided to UnitedHealthcare Community Plan enrollees.
Other factors affecting reimbursement supplement, modify or, in
some cases, supersede this policy. These factors include, but are
not limited to: federal &/or state regulatory requirements, the
physician or other provider contracts,
the enrollee’s benefit coverage documents, and/or other
reimbursement, medical or drug policies. Finally, this policy may
not be implemented exactly the same way on the different electronic
claims processing systems used by UnitedHealthcare Community Plan
due to programming or other constraints; however, UnitedHealthcare
Community Plan strives to minimize these variations.
UnitedHealthcare Community Plan may modify this reimbursement
policy at any time by publishing a new version of the policy on
this Website. However, the information presented in this policy is
accurate and current as of the date of publication. *CPT Copyright
American Medical Association. All rights reserved. CPT® is a
registered trademark of the American Medical Association.
Application
This reimbursement policy applies to UnitedHealthcare Community
Plan Medicaid products. This reimbursement policy applies to
services reported using the 1500 Health Insurance Claim Form (a/k/a
CMS-1500) or its electronic equivalent or its successor form. This
policy applies to all products and all network and non-network
physicians and other qualified health care professionals,
including, but not limited to, non-network authorized and percent
of charge contract physicians and other qualified health care
professionals.
Policy
Overview
This policy identifies circumstances where UnitedHealthcare
Community Plan will reimburse physicians and other qualified health
care professionals for High and Low Osmolar Contrast and
Radiopharmaceutical Materials. For the purposes of this policy, the
Same Group Physician or Other Qualified Health Care Professional is
defined as all physicians and/or other qualified health care
professionals of the same group rendering health care services
reporting the same Federal Tax Identification number.
Reimbursement Guidelines
Services Reported in a CMS Facility Place of Service
UnitedHealthcare Community Plan does not permit reimbursement
for the technical component or global service of an imaging
procedure to a physician or other qualified healthcare professional
when the procedure is performed in a facility Place of Service
(POS) (19, 21, 22, 23, 24, 26, 34, 51, 52, 56, or 61).
UnitedHealthcare Community Plan will not provide reimbursement to a
physician or other qualified health care professional for High
Osmolar Contrast Materials (HOCM), Low Osmolar Contrast Materials
(LOCM) or Radiopharmaceutical Materials submitted with HCPCS codes
A4641, A4642, A9500-A9700, J1245, Q3001, Q9951, Q9953, Q9954,
Q9956, Q9957 and Q9958-Q9968 with a facility POS, as
-
Reimbursement Policy
CMS 1500 Policy Number 2020R0104A
Proprietary information of UnitedHealthcare Community Plan.
Copyright 2020 United HealthCare Services, Inc. 2020R0104A
these materials would be needed in order to perform the
technical component of the imaging or therapeutic nuclear medicine
procedure. However, separate reimbursement to a physician for HOCM,
LOCM or Radiopharmaceutical Materials will be allowed in an
Ambulatory Surgical Center (ASC) (POS 24) when provided in
conjunction with eligible imaging procedures that are not included
on the Centers for Medicare and Medicaid Services (CMS) Ambulatory
Surgical Center Fee Schedule (ASCFS) Addendum BB. The technical
component, global service and associated HOCM, LOCM or
Radiopharmaceutical Materials for procedures listed on the ASCFS
Addendum BB are included in the facility case rate and not
separately reimbursable. ASCFS Eligible Imaging and Therapeutic
Procedures Code List ASCFS Nuclear Medicine Procedures Code List
ASCFS Contrast and Radiopharmaceutical Materials Code List
Service Reported in a CMS Non-Facility Place of Service
When an imaging or therapeutic nuclear medicine procedure is
performed in a non-facility setting, UnitedHealthcare Community
Plan will provide separate reimbursement to the Same Group
Physician or Other Qualified Health Care Professional for HOCM,
LOCM or Radiopharmaceutical Materials when reported on the same
date of service with a procedure code that requires contrast or
Radiopharmaceutical Materials. Additionally, UnitedHealthcare
Community Plan will also allow separate reimbursement for contrast
and Radiopharmaceutical Materials reported with a date of service
up to two days prior to a nuclear medicine imaging scan.
In accordance with CMS coding guidelines, UnitedHealthcare
Community Plan will not provide separate reimbursement for
Radiopharmaceutical Materials HCPCS code A9512 when submitted with
A9538 or A9560 on the same day by the Same Group Physician or Other
Qualified Health Care Professional.
Contrast and Radiopharmaceutical Materials Code List Eligible
Imaging and Therapeutic Procedures Code List Nuclear Medicine
Procedures Code List For more information regarding the
professional/technical concept, refer to the UnitedHealthcare
Community Plan “Professional/Technical Component” policy.
Definitions
Osmolar Contrast Materials An iodine based substance,
administered intravascularly, intra-articularly or intrathecally,
that is used to enhance the visibility of structures or fluids
within the body during an imaging procedure such as an X-ray, MRI
or CT image, or other diagnostic/interventional cardiovascular
procedures.
Radiopharmaceutical Materials
Radioactive chemical or pharmaceutical preparations, used as
diagnostic or therapeutic agents
Same Group Physician and/or Other Qualified Health Care
Professional
All physicians and/or other qualified health care professionals
of the same group reporting the same Federal Tax Identification
number.
State Exceptions
Wisconsin WI state regulation considers POS 19 as non-facility
place of service
Questions and Answers
1
Q: How was the Eligible Imaging and Therapeutic Procedures Code
List derived? A: The Eligible Imaging and Therapeutic Procedures
Code List was developed by UnitedHealthcare Community Plan based on
the following criteria:
-
Reimbursement Policy
CMS 1500 Policy Number 2020R0104A
Proprietary information of UnitedHealthcare Community Plan.
Copyright 2020 United HealthCare Services, Inc. 2020R0104A
Those codes whose CPT or HCPCS descriptor includes the terms:
with contrast, with imaging guidance (fluoroscopy or CT), or
including radiologic localization (includes contrast when
administered); and
Additional codes in which clinical review determined that
Contrast or Radiopharmaceutical Materials were required in order to
perform the service.
2
Q: Does UnitedHealthcare Community Plan reimburse for contrast
and Radiopharmaceutical materials reported with a date of service
up to two days prior to all eligible imaging or therapeutic
procedures? A: No. UnitedHealthcare Community Plan will only allow
separate reimbursement for contrast and Radiopharmaceutical
materials reported with a date of service up to two days prior to a
nuclear medicine imaging scan (CPT codes 78012-79999).
3
Q: Does UnitedHealthcare Community Plan reimburse for contrast
and Radiopharmaceutical Materials reported with an imaging and
therapeutic or nuclear medicine procedure that is denied based on
another UnitedHealthcare reimbursement policy? A: No.
UnitedHealthcare Community Plan will only allow separate
reimbursement for contrast and Radiopharmaceutical Materials when
reported with an eligible imaging and therapeutic or nuclear
medicine procedure that is also eligible for reimbursement.
Attachments
UnitedHealthcare Community Plan Contrast and
Radiopharmaceutical
Materials Codes List
This list identifies the contrast and Radiopharmaceutical
Material codes required to perform an imaging or therapeutic
procedure.
UnitedHealthcare Community Plan Nuclear Medicine Procedures
Code
List
This list identifies codes that require Radiopharmaceutical
Materials.
UnitedHealthcare Community Plan Eligible Imaging and
Therapeutic
Procedures Codes List
This list identifies codes that require contrast materials.
ASCFS Eligible Imaging and Therapeutic Procedures Code List
This list identifies imaging and therapeutic procedures that are
separately reimbursable when provided in an ASC (POS 24).
ASCFS Nuclear Medicine Procedures Code List
This list identifies nuclear medicine procedures that are
separately reimbursable when provided in an ASC (POS 24).
ASCFS Contrast and Radiopharmaceutical Materials Code
List
This list identifies Contrast and Radiopharmaceutical Material
codes that are separately reimbursable when provided in an ASC (POS
24).
Resources
-
Code
A4641
A4642
A9500
A9501
A9502
A9503
A9504
A9505
A9507
A9508
A9509
A9510
A9512
A9513
A9515
A9516
A9517
A9520
A9521
A9524
A9526
A9527
A9528
A9529
A9530
A9531
A9532
A9536
A9537
A9538
A9539
A9540
A9541
A9542
A9543
A9546
A9547
A9548
A9550
A9551
A9552
A9553
A9554
A9555
Contrast and Radiopharmaceutical Materials Code List
-
A9556
A9557
A9558
A9559
A9560
A9561
A9562
A9563
A9564
A9566
A9567
A9568
A9569
A9570
A9571
A9572
A9575
A9576
A9577
A9578
A9579
A9580
A9581
A9582
A9583
A9584
A9585
A9586
A9587
A9588
A9589
A9590
A9597
A9598
A9600
A9604
A9606
A9698
A9699
A9700
J1245
Q3001
Q9951
Q9953
Q9954
Q9956
Q9957
-
Q9958
Q9959
Q9960
Q9961
Q9962
Q9963
Q9964
Q9965
Q9966
Q9967
Q9968
Q9969
jmanzonFile Attachment112619_C&S Contrast and Radiopharm
Materials Code List_20200101.pdf
-
Code
78267
78268
78350
78351
78609
78835
ASCFS Nuclear Medicine Procedure Code List
jmanzonFile Attachment120619_C&S ASCFS Nuclear Medicine
Procedure Code List_20200101.pdf
-
Code
A4641
A4642
A9513
A9517
A9530
A9543
A9563
A9564
A9589
A9600
A9604
A9606
A9699
Q3001
Q9969
ASCFS Contrast and Radiopharmaceutical Materials Procedure Code
List
jmanzonFile Attachment013019_ASCFS Contrast and
Radiopharmaceutical Materials Procedure Code List_20190217.pdf
-
Nuclear Medicine Procedures Code List
Code
78012
78013
78014
78015
78016
78018
78020
78070
78071
78072
78075
78099
78102
78103
78104
78110
78111
78120
78121
78122
78130
78135
78140
78185
78191
78195
78199
78201
78202
78215
78216
78226
78227
78230
78231
78232
78258
78261
78262
78264
78265
78266
78267
78268
-
78278
78282
78290
78291
78299
78300
78305
78306
78315
78350
78351
78399
78414
78428
78429
78430
78431
78432
78433
78434
78445
78451
78452
78453
78454
78456
78457
78458
78459
78466
78468
78469
78472
78473
78481
78483
78491
78492
78494
78496
78499
78579
78580
78582
78597
78598
78599
-
78600
78601
78605
78606
78608
78609
78610
78630
78635
78645
78650
78660
78699
78700
78701
78707
78708
78709
78725
78730
78740
78761
78799
78800
78801
78802
78803
78804
78808
78811
78812
78813
78814
78815
78816
78830
78831
78832
78835
78999
79005
79101
79200
79300
79403
79440
79445
-
79999
jmanzonFile Attachment112019_C&S Nuclear Medicine Procedure
Code List_20200101.pdf
-
Code
0042T
0054T
0055T
0071T
0075T
0076T
0200T
0201T
0202T
0219T
0220T
0221T
0222T
0232T
0274T
0275T
0330T
0338T
0339T
0345T
0408T
0409T
0410T
0411T
0412T
0413T
0414T
0415T
0416T
0417T
0418T
0424T
0425T
0426T
0427T
0428T
0429T
0430T
0431T
0432T
0433T
0440T
0441T
0442T
ASCFS Eligible Imaging and Therapeutic Procedures Code List
-
0451T
0452T
0453T
0454T
0455T
0456T
0457T
0458T
0459T
0460T
0461T
0462T
0463T
0481T
0483T
0484T
0499T
0501T
0502T
0503T
0504T
0505T
0515T
0516T
0517T
0518T
0519T
0520T
0524T
0525T
0526T
0527T
0530T
0531T
0532T
0543T
0544T
0545T
0548T
0549T
0550T
0551T
0553T
0569T
0570T
0571T
0572T
-
0573T
0574T
0581T
0582T
0584T
0585T
0586T
0587T
0588T
10007
10008
10009
10010
10011
10012
10030
10035
10036
19081
19083
19085
19281
19283
19285
19287
19296
19297
19298
20982
20983
22510
22511
22513
22514
22526
22586
22857
22861
22862
22864
22865
22867
22868
22869
22870
23350
27096
-
27279
31622
31623
31624
31625
31626
31628
31629
31630
31631
31634
31635
31636
31638
31640
31641
31643
31645
31646
31647
31648
31649
31651
31652
31653
31654
31660
31661
32555
32557
32994
33016
33017
33018
33019
33274
33275
33340
33361
33362
33363
33364
33365
33366
33418
33951
33952
-
33957
33958
33959
33962
33963
33964
33990
33991
33992
33993
34701
34702
34703
34704
34705
34706
34707
34708
34709
34710
34711
34712
34717
34718
34841
34842
34843
34844
34845
34846
34847
34848
36221
36222
36223
36224
36225
36226
36251
36252
36253
36254
36465
36466
36473
36474
36475
-
36478
36482
36483
36572
36573
36584
36597
36598
36901
36902
36903
36904
36905
36906
36907
36908
36909
37184
37187
37188
37191
37192
37193
37197
37211
37212
37213
37214
37215
37216
37217
37218
37220
37221
37224
37225
37226
37227
37228
37229
37230
37231
37236
37238
37241
37242
37243
-
37244
37246
37247
37248
37249
38792
43206
43213
43214
43233
43252
43260
43261
43262
43263
43264
43265
43274
43275
43276
43277
43278
47490
47531
47532
47533
47534
47535
47536
47537
47538
47539
47540
47541
47542
47543
47544
49083
49084
49185
49405
49406
49407
49418
49440
49441
49442
-
49446
49450
49451
49452
49460
49465
50387
50430
50431
50432
50433
50434
50435
50436
50437
50606
50693
50694
50695
50705
50706
55706
55874
61120
61630
61635
61640
61641
61642
61645
61650
61651
62263
62264
62287
62302
62303
62304
62305
62321
62323
62325
62327
62328
62329
64451
64454
-
64461
64462
64463
64479
64483
64486
64487
64488
64489
64490
64493
64561
64624
64625
64633
64635
71555
72159
72198
73225
73725
74185
74221
74248
75956
75957
75958
75959
77048
77049
92235
92240
92242
92920
92924
92928
92933
92937
92941
92943
92977
93306
93307
93308
93350
93351
93352
-
93356
93451
93452
93453
93454
93455
93456
93457
93458
93459
93460
93461
93462
93463
93464
93563
93564
93565
93566
93567
93568
93581
93582
93583
93590
93591
93592
93653
93654
93656
G0219
G0235
G0252
G0278
G0297
S8042
S8080
S8085
jmanzonFile Attachment120619_C&S ASCFS Eligible Imaging and
Therapeutic Proc Code List_20200101.pdf
-
Code
0042T
0054T
0055T
0071T
0075T
0076T
0200T
0201T
0202T
0219T
0220T
0221T
0222T
0232T
0274T
0275T
0330T
0331T
0332T
0338T
0339T
0345T
0408T
0409T
0410T
0411T
0412T
0413T
0414T
0415T
0416T
0417T
0418T
0424T
0425T
0426T
0427T
0428T
0429T
0430T
0431T
0432T
0433T
0440T
Eligible Imaging and Therapeutic Procedures Code List
-
0441T
0442T
0451T
0452T
0453T
0454T
0455T
0456T
0457T
0458T
0459T
0460T
0461T
0462T
0463T
0481T
0483T
0484T
0499T
0501T
0502T
0503T
0504T
0505T
0515T
0516T
0517T
0518T
0519T
0520T
0524T
0525T
0526T
0527T
0530T
0531T
0532T
0543T
0544T
0545T
0548T
0549T
0550T
0551T
0553T
0558T
0569T
-
0570T
0571T
0572T
0573T
0574T
0581T
0582T
0584T
0585T
0586T
0587T
0588T
10007
10008
10009
10010
10011
10012
10030
10035
10036
19081
19083
19085
19281
19283
19285
19287
19296
19297
19298
20982
20983
22510
22511
22513
22514
22526
22586
22857
22861
22862
22864
22865
22867
22868
22869
-
22870
23350
27096
27279
31622
31623
31624
31625
31626
31628
31629
31630
31631
31634
31635
31636
31638
31640
31641
31643
31645
31646
31647
31648
31649
31651
31652
31653
31654
31660
31661
32555
32557
32994
33016
33017
33018
33019
33274
33275
33340
33361
33362
33363
33364
33365
33366
-
33418
33951
33952
33957
33958
33959
33962
33963
33964
33990
33991
33992
33993
34701
34702
34703
34704
34705
34706
34707
34708
34709
34710
34711
34712
34717
34718
34841
34842
34843
34844
34845
34846
34847
34848
36221
36222
36223
36224
36225
36226
36251
36252
36253
36254
36465
36466
-
36473
36474
36475
36478
36482
36483
36572
36573
36584
36597
36598
36901
36902
36903
36904
36905
36906
36907
36908
36909
37184
37187
37188
37191
37192
37193
37197
37211
37212
37213
37214
37215
37216
37217
37218
37220
37221
37224
37225
37226
37227
37228
37229
37230
37231
37236
37238
-
37241
37242
37243
37244
37246
37247
37248
37249
38792
43206
43213
43214
43233
43252
43260
43261
43262
43263
43264
43265
43274
43275
43276
43277
43278
47490
47531
47532
47533
47534
47535
47536
47537
47538
47539
47540
47541
47542
47543
47544
49083
49084
49185
49405
49406
49407
49418
-
49440
49441
49442
49446
49450
49451
49452
49460
49465
50387
50430
50431
50432
50433
50434
50435
50436
50437
50606
50693
50694
50695
50705
50706
55706
55874
61120
61630
61635
61640
61641
61642
61645
61650
61651
62263
62264
62287
62302
62303
62304
62305
62321
62323
62325
62327
62328
-
62329
64451
64454
64461
64462
64463
64479
64483
64486
64487
64488
64489
64490
64493
64561
64624
64625
64633
64635
70010
70015
70170
70332
70336
70370
70460
70470
70481
70482
70487
70488
70491
70492
70496
70498
70542
70543
70545
70546
70548
70549
70552
70553
70554
70555
70558
70559
-
71260
71270
71275
71551
71552
71555
72126
72127
72129
72130
72132
72133
72142
72147
72149
72156
72157
72158
72159
72191
72193
72194
72196
72197
72198
72240
72255
72265
72270
72275
72285
72295
73040
73085
73115
73201
73202
73206
73219
73220
73222
73223
73225
73525
73580
73615
73701
-
73702
73706
73719
73720
73722
73723
73725
74160
74170
74174
74175
74177
74178
74182
74183
74185
74190
74210
74220
74221
74230
74240
74246
74248
74250
74251
74262
74270
74280
74283
74340
74360
74400
74410
74415
74420
74425
74430
74440
74445
74450
74455
74470
74712
74713
74740
74742
-
74775
75561
75563
75565
75572
75573
75574
75600
75605
75625
75630
75635
75705
75710
75716
75726
75731
75733
75736
75741
75743
75746
75756
75774
75810
75820
75822
75825
75827
75831
75833
75840
75842
75860
75870
75872
75880
75885
75887
75889
75891
75894
75898
75901
75902
75956
75957
-
75958
75959
75984
75989
76000
76120
76391
76496
76497
76978
76979
76981
76982
76983
77001
77002
77003
77011
77012
77013
77014
77021
77022
77048
77049
77053
77054
77078
77084
77290
77387
77750
77761
77762
77763
77778
77789
77790
77799
92235
92240
92242
92920
92924
92928
92933
92937
-
92941
92943
92977
93306
93307
93308
93350
93351
93352
93356
93451
93452
93453
93454
93455
93456
93457
93458
93459
93460
93461
93462
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93464
93563
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93565
93566
93567
93568
93581
93582
93583
93590
93591
93592
93653
93654
93656
G0219
G0235
G0252
G0278
G0297
S8042
S8080
S8085
jmanzonFile Attachment121819_C&S Eligible Imag and
Therapeutic proc code List_20200101.pdf
-
Reimbursement Policy
CMS 1500 Policy Number 2020R0104A
Proprietary information of UnitedHealthcare Community Plan.
Copyright 2020 United HealthCare Services, Inc. 2020R0104A
Individual state Medicaid regulations, manuals & fee
schedules American Medical Association, Current Procedural
Terminology ( CPT® ) and associated publications and services
Centers for Medicare and Medicaid Services, CMS Manual System and
other CMS publications and services Centers for Medicare and
Medicaid Services, Healthcare Common Procedure Coding System, HCPCS
Release and Code Sets
History
1/1/2020 Policy Version Change Policy List Change: Eligible
Imaging and Therapeutic Procedures, Nuclear Medicine Procedures,
Contrast and Radiopharmaceutical Materials Code, ASCFS Eligible
Imaging and Therapeutic Procedures Code and ASCFS Nuclear Medicine
Procedures Code Lists Updated History Section: Entries prior to
1/1/2018 archived
11/17/2019 Policy Version Change Attachment Section Update:
ASCFS Eligible Imaging and Therapeutic Procedures Code List
Updated
6/30/2019 Policy Version Change Attachment Section Update:
Eligible Imaging and Therapeutic Procedures Code List Updated
4/26/2019 No Policy Version Change – administrative update to
word document properties
2/17/2019 Policy Version Change Attachment Section Update: ASCFS
Imaging and Therapeutic Procedure, ASCFS Nuclear Medicine
Procedure, and ASCFS Contrast and Radiopharmaceutical Materials
Code Lists Updated
2/1/2019 Annual Anniversary Date and Version Change Title
section: Removed Annual Approval information & moved policy #
to the header
1/1/2019 Policy Version Change Policy change: Removed Facility
from title placed in error Removed reference to Employer and
Individual and Medicare and Retirement in the Application section,
Policy verbiage updated to add qualified to other qualified health
care professionals Definitions Section Change: Same Group Physician
and/or Other Qualified Health Care Professional Policy List Change:
Eligible Imaging and Therapeutic Procedures, Contrast and
Radiopharmaceutical Materials, Nuclear Medicine Procedures, ASCFS
Imaging and Therapeutic Procedure, ASCFS Nuclear Medicine
Procedure, and ASCFS Contrast and Radiopharmaceutical Materials
Code Lists Updated History Section: Entries prior to 1/1/2017
archived
7/1/2018 Policy List Change: Eligible Imaging and Therapeutic
Procedures Code List Updated
5/31/2018 History: correction – typo (No new version)
3/27/2018 State Exceptions: Add Wisconsin
3/14/2018 Policy Approval Date Change (No new version)
1/1/2018 Annual Policy Version Change Policy List Change:
Eligible Imaging and Therapeutic Procedures, Contrast and
Radiopharmaceutical Materials Code and Nuclear Medicine Code Lists
Updated History Section: Entries prior to 1/1/2016 archived
1/1/2008 Implemented by UnitedHealthcare Community &
State
