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Chapter 26: Radiology Services


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Effective July 1, 2012

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

Payment policies:
Contrast material
Nuclear medicine
Radiology consultation services
Radiology reporting requirements
X-ray services

More info:
Related topics

Definitions

CPT® and HCPCS code modifiers mentioned in this chapter:

–26

Professional component

Certain procedures are a combination of the professional (—26) and technical (—TC) components.  This modifier should be used when only the professional component is performed.  When a global service is performed, neither the —26 nor the —TC modifier should be used.  (See above for information on the use of the —TC modifier.)

–52

Reduced services

Paymentis made at the fee schedule level or billed charge, whichever is less.

–LT

Left side

Although this modifier doesn’t affect payment, it should be used when billing for bilateral services.  This will help reduce duplicate bills and minimize payment delays.

–RT

Right side

Although this modifier doesn’t affect payment, it should be used when billing for bilateral services.  This will help reduce duplicate bills and minimize payment delays.

–TC

Technical component

Certain procedures are a combination of the professional (—26) and technical (—TC) components.  This modifier should be used when only the technical component is performed.  When a global service is performed, neither the —26 nor the —TC modifier should be used.  (See above for information on the use of the —26 modifier.)

–UN

Two patients served

–UP

Three patients served

–UQ

Four patients served

–UR

Five patients served

–US

Six or more patients served

Full spine study:

A full spine study is a radiologic exam of the entire spine: anteroposterior (AP) and lateral views.  Depending on the size of the film and the size of the patient, the study may require up to 6 films (the AP and lateral views of the cervical, thoracic, and lumbar spine).  (See definition of incomplete full spine study, below.)

Incomplete full spine study:

An incomplete full spine study is one in which the entire AP or lateral view is taken, but not both.  For example, a study is performed in which all AP and lateral views are obtained except for the lateral thoracic.  (See definition of full spine study, above.)


 

Payment policy: Contrast material

Services that aren’t covered

HCPCS code A9525 isn’t valid for contrast material.

Requirements for billing

Use the following HCPCS codes to bill for contrast material:

  • Low osmolar contrast material (LOCM): Q9951, Q9965 - Q9967
  • High contrast osmolar material (HOCM): Q9958 - Q9964

For LOCM, bill one unit per ml.

Providers may use either HOCM or LOCM.  The use of either type of contrast material must be based on medical necessity.

The brand name of the contrast material and the dosage must be documented in the patient’s chart.

Note: Separate payment will be made for contrast material for imaging studies.

Payment limits

HCPCS codes for LOCM are paid at a flat rate based on the AWP per ml.

 


Payment policy: Nuclear medicine

Payment limits

The standard multiple surgery policy applies to the following radiology CPT® codes for nuclear medicine services:

  • 78306,
  • 78320,
  • 78802,
  • 78803,
  • 78806,
  • 78807.

The multiple procedures reduction will be applied when these codes are billed:

  • With other codes subject to the standard multiple surgery policy, and
  • For the same patient:
    • On the same day by the same physician, or
    • By more than one physician of the same specialty in the same group practice.

Link: For more information about the standard multiple surgery payment policies, refer to the Surgery Services chapter.


Payment policy: Radiology consultation services

Services that aren’t covered

CPT® code 76140 isn’t covered.

Requirements for billing

For radiology codes where a consultation service is performed, providers must bill the specific X-ray code with modifier –26.

Attending health care providers who request second opinion consulting services are responsible for determining the necessity for the second opinion and must briefly document that justification in their chart notes.  Examples include:

  • Confirm or deny hypermobility at C5/C6,
  • Does this T12 compression fracture look old or new?,
  • Evaluate stability of L5 spondylolisthesis,
  • What is soft tissue opacity overlying sacrum?  Will it affect case management for this injury?,
  • Is opacity in lung field anything to be concerned about?, and
  • Does this disc protrusion shown on MRI look new or preexisting?

Payment limits

The insurer won’t pay separately for review of films taken previously or elsewhere if a face to face service is performed on the same date as the X-ray review.

Review of records and diagnostic studies is bundled into the E/M, chiropractic care visit, or other procedure(s) performed.

Payment for a radiological consultation will be made at the established professional component (modifier –26) rate for each specific radiology service.  A written report of the consultation is required.

Note: For specific reporting requirements, see the next section of this chapter.


Payment policy: Radiology reporting requirements

Requirements for billing

Documentation for the professional interpretation of radiology procedures is required for all professional component billing whether billed with modifier –26 or as part of the global service.

Note: Documentation refers to charting of justification, findings, diagnoses, and test result integration.

Any provider who produces and interprets his/her own imaging studies, and any radiologist who over reads imaging studies must produce a report of radiology findings to bill for the professional component.  The radiology report of findings must be in written form and must include all of the following:

  • Patient’s name, age, sex, and date of procedure, and
  • The anatomic location of the procedure and type of procedure (lumbar spine plain films, abdomen CT, cervical spine MRI, etc), and
  • Specific views (eg, AP, lateral, oblique, weight bearing, axial, sagittal, coronal, with or without contrast, etc, as applicable), and
  • Brief sentence summarizing history and/or reason for the study, such as:
    • “Lower back pain; evaluate for degenerative changes and rule out leg length inequality.”
    • “Neck pain radiating to upper extremity; rule out disc protrusion,” and
  • Description of, or listing of, imaging findings:
    • Advanced imaging reports should follow generally accepted standards to include relevant findings related to the particular type of study, and
    • Radiology reports on plain films of skeletal structures should include evaluation of osseous density and contours, important postural/mechanical considerations, assessment of any joint space abnormalities, and assessment of any important abnormal soft tissue findings, and
    • Radiology reports on chest plain films should include assessment of lung fields, bronchovascular markings, apices, tracheal air shadow, mediastinal and hilar contours, cardiovascular contours, costophrenic recesses, any abnormalities below the diaphragm, and assessment of any important osseous abnormalities shown incidentally (ribs, clavicles, scapulae, proximal humeri, spine), and

Note: Chart notes such as "X-rays are negative" or "X-rays are normal" don’t fulfill the reporting requirements described in this section and the insurer won’t pay for the professional component in these circumstances (see “Payment limits,” below).

  • Imaging impressions, which summarize and provide significance for the imaging findings described in the body of the report.  For example:
    • For a skeletal plain film report that described normal osseous density and contours and no joint abnormalities, the impression could be: “No evidence of fracture, dislocation, or gross osseous pathology.”
    • For a skeletal plain film report that described reduced bone density and thinned cortices, the impression could be: “Osteoporosis, compatible with the patient’s age.”
    • For a chest report that described vertically elongated and radiolucent lung fields, low diaphragm, and long vertical heart, the impression could be: “Emphysema.”

Attending providers who produce or order diagnostic imaging studies are responsible for acknowledging and integrating the imaging findings into their case management.  Providers must include brief documentation in their chart notes.  Examples include:

  • “Imaging rules out fracture, so rehab can proceed.”
  • “Flexion/extension plain films indicate hypermobility at C4/C5, and spinal manipulation will avoid that region.”
  • “MRI identifies disc protrusion at L4/L5, and a conservative course of inversion therapy will begin.”

Payment limits

Chart notes such as "X-rays are negative" or "X-rays are normal" don’t fulfill the reporting requirements described in this section and the insurer won’t pay for the professional component in these circumstances.


Payment policy: X-ray services

Requirements for diagnostic imaging studies

Documentation
Attending health care providers who produce or order diagnostic imaging studies are responsible for determining the necessity for the study and must briefly document that justification in their chart notes.  Examples include:

  • Plain films of the cervical spine to include obliques to rule out foraminal encroachment as possible cause for radiating arm pain, or
  • PA and lateral chest films to determine cause for dyspnea.

Technical quality

All imaging studies must be of adequate technical quality to rule out radiologically detectable pathology.

Custody

X-rays must be retained for 10 years.

Link: For more information on custody requirements, see WAC 296-20-121 and WAC 296-23-140(1) .

Requirements for billing

Billing code modifiers –RT and –LT

HCPCS modifiers –RT (right side) and –LT (left side) don’t affect payment.  They may be used with CPT® radiology codes 70010-79999 to identify duplicate procedures performed on opposite sides of the body.

Global radiology services

Global radiology services include both a technical component (producing the study) and a professional component (interpreting the study).  If only the:

  • Technical component of a radiology service is performed, then modifier –TC must be used, and only the technical component fees are allowable, and
  • Professional component of a radiology service is performed, then modifier –26 must be used, and only the professional component fees are allowable.

Incomplete full spine studies

(See definitions of full spine study and incomplete full spine studyin “Definitions” at the beginning of this chapter.)

Incomplete full spine studies in which 5 views are obtained are payable at the maximum fee schedule amount for CPT® code 72010.

Incomplete full spine studies in which 4 views are taken are payable at one half the maximum fee schedule amount for CPT® code 72010 and must be billed with modifier –52 to indicate reduced services.

Portable X-rays

Radiology services furnished in the patient’s place of residence are limited to the following tests, which must be performed under the general supervision of a physician:

  • Skeletal films involving
    • Extremities,
    • Pelvis,
    • Vertebral column, or
    • Skull
  • Chest or abdominal films that don’t involve the use of contrast media
  • Diagnostic mammograms

HCPCS codes for transportation of portable X-ray equipment R0070 (one patient) or R0075 (multiple patients) may be paid in addition to the appropriate radiology code(s). R0075 will pay based on the number of patients served and the modifier billed. Payment is outlined in the following table.

For transport portable X-ray services:

If the number of patients served is… Then the appropriate HCPCS code to bill is… Along with this billing code modifier: The maximum fee, effective July 1, 2011 is:
1 R0070 $166.16
2 R0075 –UN $83.09
3 R0075 –UP $55.39
4 R0075 –UQ $41.51
5 R0075 –UR $33.23
6 or more R0075 –US $27.70

Payment limits

Number of views

There isn’t a specific code for additional views for radiology services. Therefore, the number of X-ray views that may be paid is determined by the CPT® description for that service.

For example, the following CPT® codes for radiologic exams of the spine are payable as outlined below:

If the CPT® code is… Then it is payable:              
72020 Once for a single view
72040 Once for 2 to 3 cervical views
72050 Once for 4 or more cervical views
72052 Once, regardless of the number of cervical views it takes to complete the series

Repeat X-rays

The insurer won’t pay for excessive or unnecessary X-rays.

Repeat or serial X-rays may be performed only upon adequate clinical justification to confirm changes in the accepted condition(s).  Documented changes in objective findings or subjective complaints must support the need.

If you’re looking for more information about… Then go here:
Administrative rules for X-ray custody requirements Washington Administrative Code (WAC) 296-23-121:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-121
WAC 296-23-140(1):
http://app.leg.wa.gov/wac/default.aspx?cite=296-23-140
Becoming an L&I Provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 2:
Information for All Providers
Payment policies for surgery Chapter 29:
Surgery Services
Professional Services Fee Schedules L&I’s website:
www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2011 American Medical Association

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