Insights
News, insights, and perspectives on reimbursement
Scenario 1 – HOPPS, Commercially Insured
Scenario 3 – IDTF, Medicare
Scenario 2 – HOPPS, Medicare
Scenario 4 – IDTF, Commercially Insured
Introducing the JZ Modifier
In the 2023 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Final Rule, CMS confirmed the implementation of the new JZ Modifier. The JZ Modifier became available to use as of January 1, 2023, and is required to be implemented no later than...
2023 CMS Final Rules HOPPS and MPFS
CMS has finalized the rules for the 2023 Hospital Outpatient Prospective Payment System (HOPPS) and Medicare Physician Fee Schedule (MPFS). Please see below for some key information impacting diagnostic imaging payments for 2023. For more information on the HOPPS...
Relative Value Units
RVUs are the basic component of the Resource-Based Relative Value Scale (RBRVS), which is a methodology used by CMS and private payers to determine physician payment. RVUs are not the sole factor that defines physician compensation: the physician payment is determined...
National Correct Coding Initiative (NCCI) Edits
CMS has developed coding edits in order to prevent improper payments. There are three different types of edits. Procedure to Procedure (PTP) edits prevent improper payment when incorrect code combinations are reported. Medically Unlikely Edits (MUE) are to prevent...
Radiology Benefit Managers (RBMs)
As a personal consumer of healthcare, you may be quite familiar with your Pharmacy Benefit Manager (PBM). When going to the pharmacy to pick up your prescription (Part D) drug, in order to have your your prescription covered by insurance you are asked to provide proof...
Medicare Administrative Contractors
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare medical claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary...
Appropriate Use Criteria
As described by the Centers for Medicare and Medicaid Services (CMS), the Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare...
Hospital Price Transparency
Beginning January 1, 2022, CMS increased the penalty for some hospitals that do not comply with the Hospital Price Transparency final rule. However, it has been noted that thousands of hospitals are not in compliance. Click here to learn more.
NDC/HCPCS Crosswalk Files
Finding the Healthcare Common Procedure Coding System (HCPCS) code for a new product or drug is easier than you may think! The Centers for Medicare & Medicaid Services (CMS) publishes an updated National Drug Code (NDC)/HCPCS crosswalk file every quarter. You can...
HCPCS Coding Decisions
Since 2020, the Centers for Medicare & Medicaid Services (CMS) has been reviewing Healthcare Common Procedure Coding System (HCPCS) applications quarterly and posting their decisions with explanations on their website. To access the HCPCS application summaries,...
Physician Fee Schedule Lookup Tool
Did you know that Medicare makes reimbursement rates for procedures done in physician's offices public information? To look up procedure reimbursement rates in your area or for the National Payment Amount, check out the Centers for Medicare & Medicaid Services...
Procedure Input Files
Under Medicare, the components for many procedures are “bundled” together under one code. The bundle includes important components of the procedure, such as: staff time, disposable plastics, electricity for the building and—under the Hospital Outpatient Prospective...
Ambulatory Payment Classifications (APCs)
The Centers for Medicare and Medicaid Services (CMS) has developed Ambulatory Payment Classifications (APCs) as a method of payment for hospital outpatient services. Each APC is composed of procedures which are similar in clinical intensity, resource utilization, and...
ASP Pricing Files
The Centers for Medicare & Medicaid Services (CMS) Medicare program reimburses for Part B drugs based on the Average Sales Price (ASP) of a drug +6%. These ASP rates are submitted quarterly by drug manufacturers and are based on data from two quarters prior.¹...
ProHance® (Gadoteridol) Injection, 279.3 mg/mL
and
ProHance® MultipackTM (Gadoteridol) Injection, 279.3 mg/mL
Indications and Usage:
CENTRAL NERVOUS SYSTEM
ProHance® (Gadoteridol) Injection, 279.3 mg/mL is indicated for use in MRI in adults and pediatric patients including term neonates to visualize lesions with disrupted blood brain barrier and/or abnormal vascularity in the brain (intracranial lesions), spine and associated tissues.
EXTRACRANIAL/EXTRASPINAL HEAD AND NECK
ProHance (Gadoteridol) Injection, 279.3 mg/mL is indicated for use in MRI in adults to visualize lesions in the head and neck.
IMPORTANT SAFETY INFORMATION:
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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.
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CONTRAINDICATIONS
Contraindicated in patients with known allergic or hypersensitivity reactions to ProHance.
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 administration and resolved with prompt emergency treatment. Prior to ProHance administration, ensure the availability of trained personnel and medications to treat hypersensitivity reactions. Consider these risks, 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. Linear GBCAs cause more retention than 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.
Acute Kidney Injury: In patients with chronically reduced renal function, acute kidney injury requiring dialysis has occurred with the use of GBCAs. The risk of acute kidney injury may increase with increasing dose of the contrast agent; administer the lowest dose necessary for adequate imaging.
ADVERSE REACTIONS
The most commonly reported adverse reactions are nausea and taste perversion with an incidence ≥ 0.9%.
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 are no data on the presence in human milk, the effects on the breastfed infant, or the effects on milk production. However, published lactation data on other GBCAs indicate that 0.01 to 0.04% of the maternal gadolinium dose is present in breast milk.
Pediatric Use: The safety and effectiveness of ProHance have been established for use with MRI 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 17 years of age. Adverse reactions in pediatric patients were similar to those reported in adults. No case of NSF associated with ProHance or any other GBCA has been identified in pediatric patients ages 6 years and younger.
Please see full Prescribing Information and Patient Medication Guide for additional important safety information for/regarding ProHance (Gadoteridol) Injection, 279.3 mg/mL at https://www.braccoimaging.com/us-en/products/magnetic-resonance-imaging/prohance
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit https://www.fda.gov/Safety/MedWatch or call 1-800-FDA-1088.
ProHance is manufactured for Bracco Diagnostics Inc. by BIPSO GmbH – 78224 Singen (Germany).
ProHance is a registered trademark of Bracco Diagnostics Inc.
ProHance Multipack is a trademark of Bracco Diagnostics Inc.
All other trademarks and registered trademarks are the property of their respective owners.
Bracco Diagnostics Inc.
259 Prospect Plains Road, Building H Monroe Township, NJ 08831 USA Phone: 609-514-2200
Toll Free: 1-877-272-2269 (U.S. only) Fax: 609-514-2446
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