HCPCS Code A9577

Official Description

Injection, gadobenate dimeglumine (multihance), per ml

Short Descr	Inj multihance
Related Drugs	MultiHance
Coverage	Carrier Priced
Pricing Indicator(s)	51 – Drugs
MPI	A – Not applicable, as HCPCS priced under one methodology
BETOS	I1E – Standard imaging - nuclear medicine
TOS Code(s)	4 – Diagnostic radiology
Added Date	1/1/2008
Status Code	Statutory Exclusion (from MPFS, may be paid under other methodologies)
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Items and Services Packaged into APC Rates
ASC Payment Indicator	Packaged service/item; no separate payment made.
MUE	50
MUE	Not applicable/unspecified.
OTS Orthotic	No
CCS Clinical Classification	243 - DME and supplies

JZ	Zero drug amount discarded/not administered to any patient
JW	Drug amount discarded/not administered to any patient
MG	The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
GC	This service has been performed in part by a resident under the direction of a teaching physician
GA	Waiver of liability statement issued as required by payer policy, individual case
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
X5	Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
LT	Left side (used to identify procedures performed on the left side of the body)
GW	Service not related to the hospice patient's terminal condition
RT	Right side (used to identify procedures performed on the right side of the body)
ME	The order for this service adheres to appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
77	Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
GZ	Item or service expected to be denied as not reasonable and necessary
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
MF	The order for this service does not adhere to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
AG	Primary physician
TC	Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter