Radiology Coding Alert

Learn more about the contrast media shortage and how practices may order alternative procedures to provide care until supplies are replenished.

Sort Out COVID-Related Contrast Supply Shortage

On March 31, 2022, the Chinese government instituted a lockdown in Shanghai due to an increase in COVID-19 cases. The lockdown affected several industries, including a factory owned by GE Healthcare that produces iohexol ICM. Four companies, including GE Healthcare, Bracco Diagnostics, Bayer Corporation, and Guerbet LLC, supply the U.S. market with ICM. Iohexol accounts for 50 percent of the U.S. ICM use (https://pubs.rsna.org/doi/10.1148/radiol.221183). When the Shanghai factory was shut down, the vendors were unable to receive shipments of contrast media to fulfill orders throughout the U.S.

In an April 19, 2022, letter to consumers, GE Healthcare announced the company would be limiting orders of iohexol. On May 9, the U.S. Food and Drug Administration (FDA) added Omnipaque and Visipaque contrast media to the FDA drug shortage list. Omnipaque and Visipaque are two dyes supplied to healthcare providers in the U.S. that are made by GE Healthcare.

Examples of HCPCS Level II codes that represent ICM, such as Omnipaque and Visipaque, include:

• Q9965 (Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml)
• Q9966 (… 200-299 mg/ml iodine concentration, per ml)
• Q9967 (… 300-399 mg/ml iodine concentration, per ml)

The Shanghai factory reopened on May 16, 2022, and at that time GE Healthcare expected an 80 percent reduction in supplies through the end of June. However, in a June 2 statement, GE Healthcare expected the factory’s production capacity to “be close to 100 percent” starting the week of June 6, 2022 (www.ge.com/news/press-releases/ge-healthcare-update-on-iodinated-contrast-media).

Understand the Effect on Practices

As a result of the supply chain shortage, hospitals, radiology practices, and other specialties have been forced to ration their supplies of ICM. This rationing has led several providers to postpone procedures, including elective procedures, treatment-monitoring imaging for cancer patients, and diagnostic testing. In his May 26, 2022, testimony before the Senate Health, Education, Labor, and Pensions Committee, Robert Califf, MD, MACC, commissioner of the FDA, illustrated the gravity of the shortage. “We’ve had a number of medical illnesses in Congress lately, [and] someone with a stroke or heart attack wouldn’t be able to get an angiogram. It’s just unbelievable, but it’s happening,” Dr. Califf said.

While the manufacturer expected the Shanghai facility to be almost fully operational at the beginning of June, the company did not provide an estimate of when the shortage should end. Until the ICM supply can be replenished and distributed, the shortages and patient delays could continue throughout the summer.

Look to Alternative Procedures in the Meantime

Practices who use GE contrast media for select procedures may be struggling to find supplies and wondering what to do until the manufacturer’s supply is replenished. The American College of Radiology (ACR) Committee on Drugs and Contrast Media issued guidance on mitigating risk during the iodinated contrast shortage.

Some of the recommendations in the ACR’s guidance include:

• Search for contrast agent alternatives, which may be marketed under different brand names;
• Save contrast agents with a higher concentration for angiographic studies and multiphase studies; and
• Use alternative procedures to examine the patient, which may include noncontrast computed tomography (CT), magnetic resonance (MR) with or without gadolinium-based contrast media, and ultrasound (US) with or without US contrast media.

Using the final recommendation listed above as an example, examine this scenario:

A patient presents to your radiology practice for a CT scan of their abdomen with contrast to evaluate the patient’s acute abdominal pain. If the patient’s physician performs a physical exam and determines the patient’s abdominal pain isn’t critical, then the physician could order a noncontrast CT scan. The radiologist would then perform 74150 (Computed tomography, abdomen; without contrast material) instead of 74160 (… with contrast material(s)) to evaluate the patient’s condition.

You can read more on the ACR’s recommendations at www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Contrast-Media-Shortage.

Can Radiology Practices Request Order Changes Without Re-Authorization?

Practices use prior authorization to receive advanced approval from payers before the provider delivers a service to the patient. Prior authorization allows the practice to know if the procedure will receive payment coverage.

Before the contrast media shortage, radiology practices may have received prior authorization for several procedures that they could then put on the schedule. However, until the contrast media supply is fully restocked, practices may wish to use alternative procedures to provide care.

Normally, if an imaging order needed to be changed, the practice would require a new prior authorization. During the contrast media supply shortage, the ACR and the Radiology Business Management Association (RBMA) have written letters to payers and radiology benefit management (RBM) companies asking to allow for flexibility regarding prior authorizations. The organizations are requesting that providers have “the option of changing patient orders for CT scans with contrast as needed, without having to repeat the prior authorization process and potentially delay patient care” (www.acr.org/Advocacy-and-Economics/Advocacy-News/ Advocacy-News-Issues/In-the-May-28-2022-Issue/ACR-and-RBMA-Ask-Payers-for-Prior-Authorization-Flexibility-Due-to-Contrast-Media-Shortage).

Additionally, even though the intent of the letters was immediate flexibility, the organizations feel that prior authorization of CPT^® code families would be a best practice to be followed by payers in the future. With prior authorization for specific CPT^® codes, the provider may only perform the exact procedure as ordered and authorized as opposed to altering the exam to the patient- or clinical-specific situation that could “best answer the diagnostic question.”

For further information regarding prior authorization flexibilities, practices may wish to contact individual payers to confirm the payer’s preferences during the shortage.