IMAGING SERVICES. Inpatient diagnostic and high-technology imaging does not require prior authorization.

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1 Original Effective Date: April 27, 2010 Revision Date: January 1, 2013 IMAGING SERVICES Policy Summary NHP reimburses for medically necessary diagnostic and high-technology imaging services. Diagnostic imaging services include diagnostic radiology, mammography, bone densitometry, and ultrasound procedures. High-technology imaging services include magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computerized tomography (CT), computerized tomographic angiography (CTA), and positron emission tomography (PET). High-technology imaging services performed in an outpatient setting must be prior authorized prior to being performed. Please refer to the Authorization and Referral section of this policy for specific details. Authorization and corresponding authorization numbers for high technology imaging services may be obtained by: o Visiting the MedSolutions website o Calling MedSolutions toll-free, 8 AM to 9 PM ET at: o Faxing MedSolutions toll-free at: Complete the appropriate fax form and fax to the number above. MedSolutions will respond by fax when the authorization decision is complete. (You can obtain body part and modality specific forms on the MedSolutions website ( or by calling the MedSolutions Customer Service Department at ) Certain diagnostic and high-technology imaging services are subject to payment reduction when two or more are performed on the same day, at the same encounter. Please refer to the Service Limitations section for a complete list of the imaging services subject to payment reduction. Policy Limitations and Exceptions This policy applies to all outpatient qualifying places of service in accordance with the National Place of Service (POS) code set, excluding emergency room services. If the prescribing provider determines that an additional or different imaging study is warranted, the prescribing provider must contact MedSolutions for review and authorization of additional services prior to rendering the additional services identified which have not yet been approved. Please contact MedSolutions by faxing information to Inpatient diagnostic and high-technology imaging does not require prior authorization. Neighborhood Health Plan 1 Provider Payment Guidelines

2 Authorization and Referral Please refer to the NHP Authorization Grid for the most current prior authorization requirements. High-Technology Imaging Service NHP requires authorization prior to advanced, high-technology imaging services in an outpatient setting. The following categories of codes require prior authorization Category Codes CT/computerized tomography CTA/computerized tomographic angiography , MRI/ magnetic resonance imaging NHP Reimburses Outpatient diagnostic imaging including the following: o diagnostic radiology, o mammography, o bone densitometry, and o ultrasound procedures Outpatient high-technology imaging including the following: o magnetic resonance imaging (MRI), o magnetic resonance angiography (MRA), o computerized tomography (CT), o computerized tomographic angiography (CTA), o and positron emission tomography (PET). Low osmolar contrast for those services requiring contrast materials. Neighborhood Health Plan 2 Provider Payment Guidelines

3 NHP Does Not Reimburse Imaging Services Diagnostic ultrasound exam performed with a corresponding diagnostic ultrasound guidance procedure. Dual energy x-ray absorptiometry (DXA); body composition study. Fluoroscopic guidance and localization of needle/catheter tip for spinal injections (diagnostic or therapeutic) when billed with myelography, supervision and interpretation (S&I) codes. Global radiology services to a physician when performed in a hospital inpatient/outpatient place of service. Scintimammography. Separately for the low osmolar contrast material billed for the second MRI when two MRIs are performed at the same session. Experimental or investigational diagnostic or high-technology imaging service. Billing Limitations Claims should be filed within 90 days of the date of service. Professional services should be submitted on a CMS-1500 or electronically on an 837P. Claims should be billed with the appropriate CPT/HCPCS code. Append modifier 26 to indicate professional components that require the use of a modifier. List the referring physician and NPI number in boxes 17 and 17b of the CMS Refer to your 837P Companion Guide for specific fields. Claims must be submitted with the appropriate diagnosis code(s). Technical services should be billed on a UB-04 for or electronically on an 837I. Submit both the revenue code and the CPT/HCPCS codes. List the ordering physician and NPI number in Box 78 on the UB-04 form. Refer to your 837I Companion Guide for specific fields. Claims must be submitted with the appropriate diagnosis code(s). Append modifier TC to indicate technical components that require the use of a modifier. Global services can be billed on either a CMS-1500 or a UB-04. Claims should be billed with appropriate CPT/HCPCS codes. Claims must be submitted with the appropriate diagnosis code(s) The ordering physician and NPI number must be listed. Additional Billing Limitations Facilities billing both the technical and professional components of radiologic service are reimbursed globally according to their contract with NHP. High osmolar contrast media for CT scans that specify with contrast is included in the technical component. Only one physician will be reimbursed for the interpretation and report for any one specific service provided and billed. When two MRIs are performed at the same session, in general, no separate reimbursement is made for the contrast material used in the second MRI. Imaging Privileges: Providers must meet NHP s requirements in order to be reimbursed for imaging services. When both a CPT code and a HCPCS Level II code exist that describe the same procedure or service, bill with the CPT code unless otherwise directed. The appropriate CPT/HCPCS procedure code(s) must be submitted with the revenue code on a UB-04. When a procedure with multiple components, as described by CPT, is reported with individual codes for each of the components, the unbundled procedure codes are re-bundled and Neighborhood Health Plan 3 Provider Payment Guidelines

4 reimbursed as a single procedure. (e.g. CT with, and CT without is reimbursed with one code, CT without and with ) NHP adheres to CPT coding guidelines for reporting 3D reconstruction procedure codes and Service Limitations The codes in the table below are subject to the reimbursement reduction when submitted as being performed during the same encounter. Diagnostic Imaging Services and High-Technology Imaging Procedures Subject to Payment Reduction CPT Code Short Descriptor CPT Code Short Descriptor Magnetic image jaw joint Mri pelvis Ct head/brain w/o Mri pelvis w/o & Ct head/brain Mr angio pelvis w/o & Magnetic image jaw joint Mri pelvis Ct head/brain w/o & Ct upper extremity w/o Ct orbit/ear/fossa w/o Ct upper extremity Ct orbit/ear/fossa Ct uppr extremity w/o& Ct orbit/ear/fossa w/o& Ct angio upr extrm w/o& Ct maxillofacial w/o Mri upper extremity w/o Ct maxillofacial Mri upper extremity Ct maxillofacial w/o & Mri uppr extremity w/o& Ct soft tissue neck w/o Mri joint upr extrem w/o Ct soft tissue neck Mri joint upr extrem Ct sft tsue nck w/o & Mri joint upr extr w/o& Ct angiography head Mr angio upr extr w/o& Ct angiography neck Ct lower extremity w/o Mri orbit/face/neck w/o Ct lower extremity Mri orbit/face/neck Ct lwr extremity w/o& Mri orbt/fac/nck w/o & Ct angio lwr extr w/o& Mr angiography head w/o Mri lower extremity w/o Mr angiography head Mri lower extremity Mr angiograph head w/o& Mri lwr extremity w/o& Mr angiography neck w/o Mri jnt of lwr extre w/o Neighborhood Health Plan 4 Provider Payment Guidelines

5 70548 Mr angiography neck Mri joint of lwr extr Mr angiograph neck Mri joint lwr extr w/o& w/o& Mri brain w/o Mr ang lwr ext w or w/o Mri brain Ct abdomen w/o Mri brain w/o & Ct abdomen Fmri brain by tech Ct abdomen w/o & Ct thorax w/o Ct angio abd&pelv w/o& Ct thorax Ct angio abdom w/o & Ct thorax w/o & Ct abd & pelvis Ct angiography chest Ct abd & pelv w/contrast Mri chest w/o Ct abd & pelv 1/> regns Mri chest Mri abdomen w/o Mri chest w/o & Mri abdomen Mri angio chest w or w/o Mri abdomen w/o & Ct neck spine w/o Mri angio abdom w orw/o Ct neck spine Ct colonography dx Ct neck spine w/o & Ct colonography dx Ct chest spine w/o Cardiac mri for morph Ct chest spine Cardiac mri w/stress img Ct chest spine w/o & Cardiac mri for morph Ct lumbar spine w/o Card mri w/stress img & Ct lumbar spine Ct hrt w/o w/ca test Ct lumbar spine w/o & Ct hrt w/3d image Mri neck spine w/o Ct hrt w/3d image congen Mri neck spine Ct angio hrt w/3d image Mri chest spine w/o Ct angio abdominal arteries Mri chest spine Us exam chest Mri lumbar spine w/o Us exam abdom complete Mri lumbar spine Echo exam of abdomen Mri neck spine w/o & Us exam abdo back wall comp Mri chest spine w/o & Us exam abdo back wall lim Mri lumbar spine w/o & Us exam k transpl w/doppler Mr angio spine Echo exam uterus w/o& Ct angiograph pelv Us exam pelvic complete w/o& Ct pelvis w/o Us exam pelvic limited Neighborhood Health Plan 5 Provider Payment Guidelines

6 72193 Ct pelvis Us exam scrotum Ct pelvis w/o & Mri one breast Mri pelvis w/o Mri both breasts Codes Applicable To this Guideline Code Descriptor Comment-Billing Instructions When Detailed Specificity Required 032X Diagnostic radiology Submit with CPT/HCPCS code 0333 Radiation therapy Submit with CPT/HCPCS code 035X CT Scan Submit with CPT/HCPCS code 040x Other imaging Submit with CPT/HCPCS code 061X Magnetic resonance technology Submit with CPT/HCPCS code Diagnostic radiology/imaging CPT codes 75572, CT heart with contrast for evaluation of cardiac structure and morphology CT angiography, heart, coronary arteries and by-pass graft when present, w contrast materials including 3D image post processing Diagnostic Ultrasound have been deleted , Ultrasound pregnant uterus 76813, Ultrasound, pregnant uterus, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal, single or first gestation; each additional gestation Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures Computer aided detection with further physician review for interpretation, w/wo digitization of film radiographic images; diagnostic mammography Computer aided detection with further physician review for interpretation, w/wo digitization of film radiographic images; screening mammography 77055, Mammography ; unilateral and bilateral Screening mammography, bilateral (2 view film study of each breast) 77080, 77081, Dual energy x-ray absorptiometry (DXA), bone density study, one or Not reimbursed when billed with myelography supervision and interpretation codes (CPT ) Bill with 77055, or Bill with 77057, or G0202 Neighborhood Health Plan 6 Provider Payment Guidelines

7 more sites Nuclear medicine 78350, Bone density (bone mineral content) study, 1 or more sites; single or dual photon absorptiometry G0202 Screening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 Diagnostic mammography, producing direct digital image, unilateral, all views G0219 PET imaging, whole body, melanoma for non-covered indications. G0235 PET imaging, any site, not otherwise specified Q0092 Set up portable x-ray and have been deleted 78350, G0202 G0204 G0206 R0070 Transportation of portable x-ray equipment and personnel to home or nursing home; per trip, one patient seen Bill with Rev code 0329 Modifiers Apply modifiers in accordance with CPT and correct coding guidelines. Modifiers and descriptors are available in current CPT/HCPCS Manuals or refer to NHP Modifier Provider Payment Guideline at Modifier Modifier 52 (Reduced Services) Modifier 26 (professional component) Use: When two different physician specialties report the supervision and interpretation (S&I) services of the surgical component of an interventional radiology procedure. (e.g. a cardiologist bills for the supervision of the code, and a radiologist bills for the interpretation of the code). When only the interpretation and report were performed. Modifier TC (technical component) When only the technical services were provided Member Cost-Sharing The provider is responsible for verifying at each encounter and when applicable for each day of care when the patient is hospitalized, coverage, available benefits, and member out-of-pocket costs, copayments, coinsurance, and deductible required, if any. Neighborhood Health Plan 7 Provider Payment Guidelines

8 Definitions Imaging: The production of diagnostic images, e.g., radiography, ultrasonography, or scintillation photography. Computed Tomographic Angiography (CTA): A non-invasive technique for imaging vessels. The information obtained from the CTA is used in evaluation of vascular anatomy (e.g. renal or liver transplant donors, congenital anomalies), vascular disorders (e.g. aortic or intracranial aneurysms, renal artery or carotid stenosis), and vascular trauma (e.g. aortic laceration) and in follow-up of organ transplantation. The key distinction between CTA and computed tomography (CT) is that CTA includes reconstruction post-processing of angiographic images and interpretation. If reconstruction is not done, it is not a CTA study. Dual-energy x-ray absorptiometry (DXA): An enhanced form of x-ray technology used to measure bone loss, most often performed on the lower spine and hips. DXA is today s established standard of measuring bone mineral density (BMD). Radiology: Radiology services include the study of images of the human body performed by a radiologist using different techniques or modalities, including but not limited to bone densitometry, computed tomography/tomographic angiography, magnetic resonance imaging/ angiography, mammography, nuclear medicine, position emission tomography and ultrasound procedures. X-ray (radiograph): A non-invasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. Computed Tomography Scan (CT scan): Also known as computerized axial tomography. The test may involve injecting a radioactive contrast into the body. Computers are used to scan for radiation and create cross-sectional images of internal organs. Magnetic Resonance Imaging (MRI): MRI uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures. Magnetic Resonance Angiography (MRA): Magnetic resonance angiography is used to generate images of the arteries in order to evaluate them for stenosis (abnormal narrowing), occlusion or aneurysms (vessel wall dilatations, at risk of rupture). Positron Emission Tomography (PET): Positron emission tomography (PET) is a nuclear medical imaging technique that produces a three-dimensional image or picture of functional processes in the body. Technical Component (TC): The technical component is the equipment and technician performing the test. This is identified by adding modifier TC to the procedure code identified for the technical component charge. Professional Component (PC): The professional component is the interpretation of the results of the test. When the professional component is reported separately the service may be identified by adding modifier 26. Global: Global Billing in an office setting - PC and TC services furnished in a physician s office, a freestanding imaging or radiation oncology center, or leased hospital radiology department, or other setting that is not part of a hospital. Neighborhood Health Plan 8 Provider Payment Guidelines

9 High-Technology: High-technology imaging allows doctors to view internal body structures in more detail. High-tech imaging procedures typically include MRIs (magnetic resonance imaging), MRAs (magnetic resonance angiography), MRSs (magnetic resonance spectroscopy), CT (computed tomography) scans, CTA (computed tomography angiography) scans, PET (positron emission tomography) scans and nuclear cardiac imaging. References AMA-CPT Manual, 2013 AMA-HCPCS Level II Code Manual, 2013 CMS 2013 Medicare Physician Fee Schedule RVU Table Diagnostic Imaging Indicator 88 CPT Assistant published by the American Medical Association NHP Obstetrical Services-Professional Provider Payment Guidelines CMS Transmittal 1040, Change Request 7703 Publication History Topic: Imaging Services Owner: Provider Network Management April 27, 2010: Original documentation May 19, 2011: Authorization grid, cost sharing, NHP Reimburses grid, disclaimer updated April 23, 2012: Updated 2012 CPT codes, MPFS radiology indicator 88 codes and payment methodology effective 07/01/2012, and referral grid. January 1, 2013: Added 2013 CPT codes and updated, authorization grid and removed deleted codes. This document is designed for informational purposes only. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization/notification and utilization management guidelines when applicable, adherence to plan policies and procedures, claims editing logic, and provider contractual agreement. In the event of a conflict between this payment guideline and the provider s agreement, the terms and conditions of the provider s agreement shall prevail. Neighborhood Health Plan utilizes McKesson s claims editing software, ClaimCheck, a clinically oriented, automated program that identifies the appropriate set of procedures eligible for provider reimbursement by analyzing the current and historical procedure codes billed on a single date of service and/or multiple dates of service, and also audits across dates of service to identify the unbundling of pre and post-operative care. Questions may be directed to Provider Network Management at prweb@nhp.org. Neighborhood Health Plan 9 Provider Payment Guidelines