Radiology Services Reimbursement Policy

Radiology Services Reimbursement Policy
Corporate Reimbursement Policy
Radiology Services Reimbursement Policy
File Name:
Origination:
Last Review:
Next Review:
radiology_services_reimbursement_policy
10/2011
2/2017
12/2017
Description of Procedure or Service
Many diagnostic services are composed of a technical and a professional component.
The technical component refers to the equipment and technician performing the test. It is identified
by adding modifier –TC to the procedure code.
The professional component refers to the interpretation of the results of the test. When the
professional component is reported separately the service may be identified by adding modifier -26 to
the procedure code. Interpretation of a diagnostic procedure includes a written report.
When multiple diagnostic imaging services are performed during a single session, most of the clinical
labor activities and most supplies are not performed or furnished twice. The following clinical labor
activities are performed once during the session and are duplicated for subsequent procedures,
creating an overlap in the services comprising the separately billed technical components:
• Greeting the patient,
• Positioning and escorting the patient,
• Providing education and obtaining consent,
• Retrieving prior exams,
• Setting up the IV,
• Preparing and cleaning the room.
In addition, the supplies used are not duplicated for subsequent procedures.
See also policies titled:
“Bundling Guidelines”
“Pricing and Adjudication Principles for Professional Providers”
“Modifier Guidelines”
“Multiple Surgical Procedure Guidelines for Professional Providers”
“Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic
Cardiovascular and Ophthalmology Procedures”
Policy
The multiple procedure payment reduction on diagnostic imaging applies when multiple services are
furnished by the same physician or physicians in the same group practice, to the same patient, in the
same session, on the same day. The allowance for the technical component of the primary procedure
is 100%. The allowance for the technical component of the second and each subsequent imaging
procedure is 50%.
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An Independent Licensee of the Blue Cross and Blue Shield Association
Radiology Services Reimbursement Policy
Benefits Application
This medical policy relates only to the services or supplies described herein. Please refer to the Member's
Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design;
therefore member benefit language should be reviewed before applying the terms of this medical policy.
When the reduced allowance for technical components of multiple radiology
services will be applicable:
The multiple procedure reduction applies to individual providers who furnish multiple services to the
same patient in the same session on the same day as well as to providers in the same group practice
who furnish multiple services to the same patient in the same session on the same day.
When the reduced allowance for technical components of multiple radiology
services will not be applicable:
The reduced allowance for the technical component of the second and subsequent procedures will not
apply when:
• Multiple procedures are billed, appended with an appropriate modifier to indicate the
procedure was done on the same day but not during the same session.
• If a global fee is charged by one provider, an additional component fee from another provider
will not be reimbursed. (Global fees include both a professional and technical component.)
Multiple procedure payment reductions do not apply to professional component services.
Policy Guidelines
Benefits will be determined based on 100% of the allowed amount for the primary procedure. The
primary procedure is considered the service with the higher RVU of current year NC Medicare rates.
Services provided on an inpatient basis are not subject to the reduced allowance for the overlapping
technical components.
When multiple procedures are obtained on the same patient in the same setting and billed on a global
basis (technical and professional fees billed on one claim line), reduced allowance applies to the
technical component only.
This policy applies to the following imaging procedures:
• Ultrasound
• MRI/MRA
• CT/CTA
High tech imaging services (CT, MRI, PET) in an outpatient setting may require prior review.
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it
will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies
on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the
Category Search on the Medical Policy search page.
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An Independent Licensee of the Blue Cross and Blue Shield Association
Radiology Services Reimbursement Policy
Applicable service codes:
70336,70450,70460,70470,70480,70481,70482,70486,70487,70488,70490,70491,70492,70496,70498,
70540,70542,70543,70544,70545,70546,70547,70548,70549,70551,70552,70553,70554,71250,71260,
71270,71275,71550,71551,71552,71555,72125,72126,72127,72128,72129,72130,72131,72132,72133,
72141,72142,72146,72147,72148,72149,72156,72157,72158,72159,72191,72192,72193,72194,72195,
72196,72197,72198,73200,73201,73202,73206,73218,73219,73220,73221,73222,73223,73225,73700,
73701,73702,73706,73718,73719,73720,73721,73722,73723,73725,74150,74160,74170,74174,74175,
74176,74177,74178,74181,74182,74183,74185,74261,74262,75557,75559,75561,75563,75571,75572,
75573,75574,75635,76604,76700,76705, 76770, 76775,76776, ,76831,76856,76857,76870, 77058,77059
Scientific Background and Reference Sources
Medical Director review June 2011
Medical Director review October 2011
Medical Director review – 2/2017
Policy Implementation/Update Information
11/21/12
Notification for policy effective date 1/21/2013. Note: this article is revised from the original
version and replaces any other versions released. This medical policy was previously issued and
later retracted pending an administrative hearing with the North Carolina Department of
Insurance (NCDOI). The hearing process is now complete, and this policy is being reissued
consistent with the hearing decision. You can view the NCDOI’s final decision granting
summary judgment in favor of BCBSNC on our website or at www.ncdoi.com.
5/26/17
Minor changes to Description section for clarity. Policy statement revised to read: The multiple
procedure payment reduction on diagnostic imaging applies when multiple services are
furnished by the same physician or physicians in the same group practice, to the same
patient, in the same session, on the same day. The allowance for the technical component
of the primary procedure is 100%. The allowance for the technical component of the
second and each subsequent imaging procedure is 50%. The “when reductions are applied”
section revised to read: The multiple procedure reduction applies to individual providers
who furnish multiple services to the same patient in the same session on the same day as
well as to providers in the same group practice who furnish multiple services to the same
patient in the same session on the same day. The following statement was added to the
“when reductions are not applied” section: Multiple procedure payment reductions do not
apply to professional component services. The following were added to the list of applicable
codes: 70336, 70554, 72159, 73225, 74174, 75557, 75559, 75571, 75572, 75573, 75574,
76776, 76870. Code 76778 was deleted. Notification 5/26/2017 for policy effective date
8/1/2017. (an)
Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are
determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and
subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational
purposes only and is based on research of current medical literature and review of common medical practices in the treatment
and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review
and revise its medical policies periodically.
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An Independent Licensee of the Blue Cross and Blue Shield Association
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