Part B Insider (Multispecialty) Coding Alert

Published on Sat Oct 07, 2006 PDF

Carriers won't cover Definity if they deny the echocardiogram

Watch out: Many providers are still billing the incorrect code for injectable contrast agent Perflutren, better known as Definity.
Medicare, and most other payors, switched in 2005 from A9700 to Q9775 for Definity. If you-re still billing A9700, you could face delays in getting paid--or even denials.

Problem: In general, many carriers won't pay for Definity unless you can convince them of the medical necessity for this contrast agent, say coders.

Policy: Only one Medicare contractor has put out a policy specifically for Definity. Adminastar Federal put out a Definity policy on the facility (fiscal intermediary) side, which clarifies the medical necessity for this agent.

According to Adminastar, you can bill for Definity when a transthoracic echocardiogram (TTE) without using contrast fails to provide enough crucial information about the patient's left ventricular function. The physician uses Definity to opacify the left ventricular chamber and to improve visibility of the left ventricular border.

You shouldn't use Definity if the patient has -known cardiac shunts,- or a known hypersensitivity to octafluoropropane, Adminastar says. The doctor shouldn't inject Definity directly into the artery, and should be careful with patients who have -compromised pulmonary vasculature.- Also, the Food & Drug Administration hasn't approved Definity for use with pharmacologic stress agents.
If the carrier denies the main echocardiography procedure, then it will also deny the use of Definity as contrast, Adminastar adds.

Part B carrier Palmetto GBA says it will cover contrast agents such as Definity to provide more visibility in order to:

- Evaluate myocardial ischemia
- Quantify myocardial perfusion during stress
- Identify the -area at risk- during acute myocardial infarction
- Determine the success of reperfusion interventions
- Assess myocardial viability

Follow your carrier's policy: If your carrier has a coverage policy for TTE, make sure to follow its documentation guidelines, advises Anne Karl, coding & compliance specialist with the St. Paul Heart Clinic.

Palmetto and other carriers say you should only use A9700 with contrast agents other than Definity or Optison. But some carriers still require unspecified code A9700 for Definity, says Janel Peterson with Bergan Cardiology Specialists in Omaha, NE. Her carrier won't accept Q9775 and still wants to receive a paper copy of the invoice for Definity before it-ll pay for the contrast agent.

Send a doctor's letter: When Maine Medical Center in Portland bills for Definity, it always includes a signed letter from the doctor, explaining the medical necessity for this particular contrast agent, says Lorraine Bacon.