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Coding for abbreviated breast MRI scans with and without contrast

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Q.

We are beginning to perform abbreviated breast screening magnetic resonance imaging (MRI) scans without and with contrast. They have fewer sequences and take about half the amount of time of a regular breast MRI. This will be done without contrast, so would we report CPT® code 77049-52 or an unlisted CPT code?

A.

MRI code descriptions do not state required elements or a required number of sequences. As such, they should be tailored to the medical need of the patient. Therefore, it is not necessary to add modifier 52 to the appropriate CPT code. Report CPT code 77049 if a bilateral exam is performed, or CPT code 77048 if a unilateral exam is performed. If billing for outpatient hospital under OPPS, report code C8905 for a unilateral exam, or C8908 for a bilateral exam.  As a screening exam, the diagnosis code submitted should be Z12.39.

Remember to also report the appropriate HCPCS code for the contrast material used.  For instance, if MultiHance®(gadobenate dimeglumine) injection, 529 mg/mL  is used, you would report A9577 for a single use vial, or A9578 for MultiHance® Multipack™ (gadobenate dimeglumine) injection, 529 mg/mL.  Both of these HCPCS codes are billed per mL administered.  The HCPCS code for the contrast material is packaged under OPPS for outpatient hospitals but should be reported.  When performed in an office or imaging center (such as an IDTF), Medicare will reimburse for the contrast material separately.  In addition, in an office or imaging center, Medicare will again reimburse for the discarded amount of contrast material from single use vials.  The discarded amount and product must be documented in the medical records and is billed on a separate claim line from the amount administered to the patient.  Add modifier -JW to the claim line for the discarded amounts.  For instance, if you provide 16 mL out of a 20 mL vial and discard 4 mL, you would report A9577 x 16 on one claim line and A9577-JW x 4 on a second claim line.

See the Clinical Examples in Radiology, Volume 16, Issue 1, Winter 2020 issue for a Q & A from the American Medical Association (AMA)/American College of Radiology (ACR) regarding this situation.  The CPT codes and full descriptions are:

77048   Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral

77049   Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral

C8905   Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral

C8908   Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral

A9577  Injection, gadobenate dimeglumine (MultiHance), per ml

A9578  Injection, gadobenate dimeglumine (MultiHance Multipack), per ml

 

IMPORTANT SAFETY INFORMATION | INDICATIONS AND USAGE

MultiHance® (gadobenate dimeglumine) injection, 529 mg/mL
and
MultiHance® Multipack™ (gadobenate dimeglumine) injection, 529 mg/mL

Indications and Usage:
MultiHance® (gadobenate dimeglumine) injection, 529 mg/mL is a gadolinium-based contrast agent indicated for intravenous use in:

  • Magnetic resonance imaging (MRI) of the central nervous system (CNS) in adults and pediatric patients (including term neonates) to visualize lesions with abnormal blood-brain barrier or abnormal vascularity of the brain, spine, and associated tissues and
  • Magnetic resonance angiography (MRA) to evaluate adults with known or suspected renal or aorto-ilio-femoral occlusive vascular disease


IMPORTANT SAFETY INFORMATION:
WARNING: NEPHROGENIC SYSTEMIC FIBROSIS

Gadolinium-based contrast agents (GBCAs) increase the risk for NSF among patients with impaired elimination of the drugs. Avoid use of GBCAs in these patients unless the diagnostic information is essential and not available with non-contrasted MRI or other modalities. NSF may result in fatal or debilitating systemic fibrosis affecting the skin, muscle and internal organs.

  • The risk for NSF appears highest among patients with:
    • chronic, severe kidney disease (GFR <30 mL/min/1.73m2) or
    • acute kidney injury.
  • Screen patients for acute kidney injury and other conditions that may reduce renal function. For patients at risk for chronically reduced renal function (e.g. age > 60 years, hypertension or diabetes), estimate the glomerular filtration rate (GFR) through laboratory testing.
  • For patients at highest risk for NSF, do not exceed the recommended MultiHance dose and allow a sufficient period of time for elimination of the drug from the body prior to re-administration.

 

CONTRAINDICATIONS

MultiHance is contraindicated in patients with known allergic or hypersensitivity reactions to gadolinium-based contrast agents.

WARNINGS AND PRECAUTIONS

Nephrogenic Systemic Fibrosis: NSF has occurred in patients with impaired elimination of GBCAs. Higher than recommended dosing or repeated dosing appears to increase risk.

Hypersensitivity Reactions: Anaphylactic and anaphylactoid reactions have been reported, involving cardiovascular, respiratory, and/or cutaneous manifestations. Some patients experienced circulatory collapse and died. In most cases, initial symptoms occurred within minutes of MultiHance administration and resolved with prompt emergency treatment. Consider the risk for hypersensitivity reactions, especially in patients with a history of hypersensitivity reactions or a history of asthma or other allergic disorders.

Gadolinium Retention:  Gadolinium is retained for months or years in several organs. The highest concentrations have been identified in the bone, followed by brain, skin, kidney, liver, and spleen. At equivalent doses, retention varies among the linear agents. Retention is lowest and similar among the macrocyclic GBCAs. Consequences of gadolinium retention in the brain have not been established, but they have been established in the skin and other organs in patients with impaired renal function. Minimize repetitive GBCA imaging studies, particularly closely spaced studies when possible.

Acute Renal Failure: In patients with renal insufficiency, acute renal failure requiring dialysis or worsening renal function have occurred with the use of GBCAs. The risk of renal failure may increase with increasing dose of the contrast agent. Screen all patients for renal dysfunction by obtaining a history and/or laboratory tests.

Extravasation and Injection Site Reactions: Extravasation of MultiHance may lead to injection site reactions, characterized by local pain or burning sensation, swelling, blistering, and necrosis. Exercise caution to avoid local extravasation during intravenous administration of MultiHance.

Cardiac Arrhythmias: Cardiac arrhythmias have been observed in patients receiving MultiHance in clinical trials. Assess patients for underlying conditions or medications that predispose to arrhythmias. The effects on QTc by MultiHance dose, other drugs, and medical conditions were not systematically studied.

Interference with Visualization of Certain Lesions: Certain lesions seen on non-contrast images may not be seen on contrast images. Exercise caution when interpreting contrast MR images in the absence of companion non-contrast MR images.

ADVERSE REACTIONS

The most commonly reported adverse reactions are nausea (1.3%) and headache (1.2%).

USE IN SPECIFIC POPULATIONS

Pregnancy: GBCAs cross the human placenta and result in fetal exposure and gadolinium retention. Use only if imaging is essential during pregnancy and cannot be delayed.

Lactation: There is no information on the effects of the drug on the breastfed infant or the effects of the drug on milk production. However, limited literature reports that breastfeeding after MultiHance administration to the mother would result in the infant receiving an oral dose of 0.001%-0.04% of the maternal dose.

Pediatric Use: MultiHance is approved for intravenous use for MRI of the CNS to visualize lesions with abnormal blood brain barrier or abnormal vascularity of the brain, spine, and associated tissues in pediatric patients from birth, including term neonates, to less than 17 years of age. Adverse reactions in pediatric patients were similar to those reported in adults. No dose adjustment according to age is necessary in pediatric patients two years of age and older. For pediatric patients, less than 2 years of age, the recommended dosage range is 0.1 to 0.2 mL/kg. The safety of MultiHance has not been established in preterm neonates.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

Please click here for Prescribing Information and Patient Medication Guide for additional important safety information for/regarding MultiHance (gadobenate dimeglumine) injection, 529 mg/mL.

Please click here for Prescribing Information and Patient Medication Guide for additional important safety information for/regarding MultiHance Multipack.

MultiHance is manufactured for Bracco Diagnostics Inc. by BIPSO GmbH – 78224 Singen (Germany) and by Patheon Italia S.p.A., Ferentino, Italy.

MultiHance is a registered trademark of Bracco International B.V.

MultiHance Multipack is a trademark of Bracco International B.V.