Chapter 26: Radiology Services

Transcription

1 Payment P licies fr Healthcare S ervices P rvided t Injured Wrkers and C rime Victims Chapter 26: Radilgy Services E ffective J uly 1, 2012 Link: Lk fr pssible updates and crrectins t these payment plicies at T able f c ntents Page Definitins Payment plicies: Cntrast material Nuclear medicine Radilgy cnsultatin services Radilgy reprting requirements X-ray services Mre inf: Related tpics CPT cdes and descriptins nly are 2011 American Medical Assciatin 26-1

2 Payment Plicies Chapter 26: R adilgy S ervices Definitins CPT and HCPCS cde mdifiers mentined in this chapter: LT RT TC Prfessinal cmpnent Certain prcedures are a cmbinatin f the prfessinal ( 26) and technical ( TC) cmpnents. This mdifier shuld be used when nly the prfessinal cmpnent is perfrmed. When a glbal service is perfrmed, neither the 26 nr the TC mdifier shuld be used. (See abve fr infrmatin n the use f the TC mdifier.) Reduced services Payment is made at the fee schedule level r billed charge, whichever is less. Left side Althugh this mdifier desn t affect payment, it shuld be used when billing fr bilateral services. This will help reduce duplicate bills and minimize payment delays. Right side Althugh this mdifier desn t affect payment, it shuld be used when billing fr bilateral services. This will help reduce duplicate bills and minimize payment delays. Technical cmpnent Certain prcedures are a cmbinatin f the prfessinal ( 26) and technical ( TC) cmpnents. This mdifier shuld be used when nly the technical cmpnent is perfrmed. When a glbal service is perfrmed, neither the 26 nr the TC mdifier shuld be used. (See abve fr infrmatin n the use f the 26 mdifier.) UN Tw patients served UP Three patients served UQ Fur patients served UR Five patients served US Six r mre patients served F ull s pine s tudy: A full spine study is a radilgic exam f the entire spine: anterpsterir (AP) and lateral views. Depending n the size f the film and the size f the patient, the study may require up t 6 films (the AP and lateral views f the cervical, thracic, and lumbar spine). (See definitin f incmplete full s pine study, belw.) 26-2 CPT cdes and descriptins nly are 2011 American Medical Assciatin

3 Chapter 26: R adilgy S ervices Payment Plicies Incmplete full s pine s tudy: An incmplete full spine study is ne in which the entire AP r lateral view is taken, but nt bth. Fr example, a study is perfrmed in which all AP and lateral views are btained except fr the lateral thracic. (See definitin f full s pine s tudy, abve.) CPT cdes and descriptins nly are 2011 American Medical Assciatin 26-3

4 Payment Plicies Chapter 26: R adilgy S ervices Payment plicy: Cntrast material S ervices that aren t cvered HCPCS cde A9525 isn t valid fr cntrast material. R equirements fr billing Use the fllwing HCPCS cdes t bill fr cntrast material: Lw smlar cntrast material (LOCM): Q9951, Q Q9967 High cntrast smlar material (HOCM): Q Q9964 Fr LOCM, bill ne unit per ml. Prviders may use either HOCM r LOCM. The use f either type f cntrast material must be based n medical necessity. The brand name f the cntrast material and the dsage must be dcumented in the patient s chart. Nte: Separate payment will be made fr cntrast material fr imaging studies. Payment limits HCPCS cdes fr LOCM are paid at a flat rate based n the AWP per ml CPT cdes and descriptins nly are 2011 American Medical Assciatin

5 Chapter 26: R adilgy S ervices Payment Plicies Payment plicy: Nuclear medicine Payment limits The standard multiple surgery plicy applies t the fllwing radilgy CPT cdes fr nuclear medicine services: 78306, 78320, 78802, 78803, 78806, The multiple prcedures reductin will be applied when these cdes are billed: With ther cdes subject t the standard multiple surgery plicy, and Fr the same patient: On the same day by the same physician, r By mre than ne physician f the same specialty in the same grup practice. Link: Fr mre infrmatin abut the standard multiple surgery payment plicies, refer t the Surgery Services chapter. CPT cdes and descriptins nly are 2011 American Medical Assciatin 26-5

6 Payment Plicies Chapter 26: R adilgy S ervices Payment plicy: R adilgy cnsultatin services S ervices that aren t cvered CPT cde isn t cvered. R equirements fr billing Fr radilgy cdes where a cnsultatin service is perfrmed, prviders must bill the specific X-ray cde with mdifier 26. Attending health care prviders wh request secnd pinin cnsulting services are respnsible fr determining the necessity fr the secnd pinin and must briefly dcument that justificatin in their chart ntes. Examples include: Cnfirm r deny hypermbility at C5/C6, Des this T12 cmpressin fracture lk ld r new?, Evaluate stability f L5 spndyllisthesis, What is sft tissue pacity verlying sacrum? Will it affect case management fr this injury?, Is pacity in lung field anything t be cncerned abut?, and Des this disc prtrusin shwn n MRI lk new r preexisting? Payment limits The insurer wn t pay separately fr review f films taken previusly r elsewhere if a face t face service is perfrmed n the same date as the X-ray review. Review f recrds and diagnstic studies is bundled int the E/M, chirpractic care visit, r ther prcedure(s) perfrmed. Payment fr a radilgical cnsultatin will be made at the established prfessinal cmpnent (mdifier 26) rate fr each specific radilgy service. A written reprt f the cnsultatin is required. Nte: Fr specific reprting requirements, see the next sectin f this chapter CPT cdes and descriptins nly are 2011 American Medical Assciatin

7 Chapter 26: R adilgy S ervices Payment Plicies Payment plicy: R adilgy reprting requirements R equirements fr billing Dcumentatin fr the prfessinal interpretatin f radilgy prcedures is required fr all prfessinal cmpnent billing whether billed with mdifier 26 r as part f the glbal service. Nte: Dcumentatin refers t charting f justificatin, findings, diagnses, and test result integratin. Any prvider wh prduces and interprets his/her wn imaging studies, and any radilgist wh ver reads imaging studies must prduce a reprt f radilgy findings t bill fr the prfessinal cmpnent. The radilgy reprt f findings must be in written frm and must include all f the fllwing: Patient s name, age, sex, and date f prcedure, and The anatmic lcatin f the prcedure and type f prcedure (lumbar spine plain films, abdmen CT, cervical spine MRI, etc), and Specific views (eg, AP, lateral, blique, weight bearing, axial, sagittal, crnal, with r withut cntrast, etc, as applicable), and Brief sentence summarizing histry and/r reasn fr the study, such as: Lwer back pain; evaluate fr degenerative changes and rule ut leg length inequality. Neck pain radiating t upper extremity; rule ut disc prtrusin, and Descriptin f, r listing f, imaging findings: Advanced imaging reprts shuld fllw generally accepted standards t include relevant findings related t the particular type f study, and Radilgy reprts n plain films f skeletal structures shuld include evaluatin f sseus density and cnturs, imprtant pstural/mechanical cnsideratins, assessment f any jint space abnrmalities, and assessment f any imprtant abnrmal sft tissue findings, and CPT cdes and descriptins nly are 2011 American Medical Assciatin 26-7

8 Payment Plicies Chapter 26: R adilgy S ervices Radilgy reprts n chest plain films shuld include assessment f lung fields, brnchvascular markings, apices, tracheal air shadw, mediastinal and hilar cnturs, cardivascular cnturs, cstphrenic recesses, any abnrmalities belw the diaphragm, and assessment f any imprtant sseus abnrmalities shwn incidentally (ribs, clavicles, scapulae, prximal humeri, spine), and Nte: Chart ntes such as "X-rays are negative" r "X-rays are nrmal" dn t fulfill the reprting requirements described in this sectin and the insurer wn t pay fr the prfessinal cmpnent in these circumstances (see Payment limits, belw). Imaging impressins, which summarize and prvide significance fr the imaging findings described in the bdy f the reprt. Fr example: Fr a skeletal plain film reprt that described nrmal sseus density and cnturs and n jint abnrmalities, the impressin culd be: N evidence f fracture, dislcatin, r grss sseus pathlgy. Fr a skeletal plain film reprt that described reduced bne density and thinned crtices, the impressin culd be: Osteprsis, cmpatible with the patient s age. Fr a chest reprt that described vertically elngated and radilucent lung fields, lw diaphragm, and lng vertical heart, the impressin culd be: Emphysema. Attending prviders wh prduce r rder diagnstic imaging studies are respnsible fr acknwledging and integrating the imaging findings int their case management. Prviders must include brief dcumentatin in their chart ntes. Examples include: Imaging rules ut fracture, s rehab can prceed. Flexin/extensin plain films indicate hypermbility at C4/C5, and spinal manipulatin will avid that regin. MRI identifies disc prtrusin at L4/L5, and a cnservative curse f inversin therapy will begin. Payment limits Chart ntes such as "X-rays are negative" r "X-rays are nrmal" dn t fulfill the reprting requirements described in this sectin and the insurer wn t pay fr the prfessinal cmpnent in these circumstances CPT cdes and descriptins nly are 2011 American Medical Assciatin

9 Chapter 26: R adilgy S ervices Payment Plicies P ayment plicy: X-ray services R equirements fr diagns tic imaging s tudies Dcumentatin Attending health care prviders wh prduce r rder diagnstic imaging studies are respnsible fr determining the necessity fr the study and must briefly dcument that justificatin in their chart ntes. Examples include: Plain films f the cervical spine t include bliques t rule ut framinal encrachment as pssible cause fr radiating arm pain, r PA and lateral chest films t determine cause fr dyspnea. Technical quality All imaging studies must be f adequate technical quality t rule ut radilgically detectable pathlgy. Custdy X-rays must be retained fr 10 years. Link: Fr mre infrmatin n custdy requirements, see WAC and WAC (1). R equirements fr billing Billing cde mdifiers RT and LT HCPCS mdifiers RT (right side) and LT (left side) dn t affect payment. They may be used with CPT radilgy cdes t identify duplicate prcedures perfrmed n ppsite sides f the bdy. CPT cdes and descriptins nly are 2011 American Medical Assciatin 26-9

10 Payment Plicies Chapter 26: R adilgy S ervices Glbal radilgy services Glbal radilgy services include bth a technical cmpnent (prducing the study) and a prfessinal cmpnent (interpreting the study). If nly the: Technical cmpnent f a radilgy service is perfrmed, then mdifier TC must be used, and nly the technical cmpnent fees are allwable, and Prfessinal cmpnent f a radilgy service is perfrmed, then mdifier 26 must be used, and nly the prfessinal cmpnent fees are allwable. Incmplete full spine studies (See definitins f full spine study and incmplete full spine study in Definitins at the beginning f this chapter.) Incmplete full spine studies in which 5 views are btained are payable at the maximum fee schedule amunt fr CPT cde Incmplete full spine studies in which 4 views are taken are payable at ne half the maximum fee schedule amunt fr CPT cde and must be billed with mdifier 52 t indicate reduced services. Prtable X-rays Radilgy services furnished in the patient s place f residence are limited t the fllwing tests, which must be perfrmed under the general supervisin f a physician: Skeletal films invlving, Extremities, Pelvis, Vertebral clumn, r Skull, Chest r abdminal films that dn t invlve the use f cntrast media, Diagnstic mammgrams. HCPCS cdes fr transprtatin f prtable X-ray equipment R0070 (ne patient) r R0075 (multiple patients) may be paid in additin t the apprpriate radilgy cde(s). R0075 will pay based n the number f patients served and the mdifier billed. Payment is utlined in the fllwing table CPT cdes and descriptins nly are 2011 American Medical Assciatin

11 Chapter 26: Radilgy Services Payment Plicies Fr transprt prtable X-ray services: If the number f patients served is Then the apprpriate HCPCS cde t bill is Alng with this billing cde mdifier: 1 R0070 $ R0075 UN $ R0075 UP $ R0075 UQ $ R0075 UR $ r mre R0075 US $27.70 The maximum fee, effective July 1, 2012 is: Payment limits Number f views There isn t a specific cde fr additinal views fr radilgy services. Therefre, the number f X-ray views that may be paid is determined by the CPT descriptin fr that service. Fr example, the fllwing CPT cdes fr radilgic exams f the spine are payable as utlined belw: If the CPT cde is Then it is payable: Once fr a single view Once fr 2 t 3 cervical views Once fr 4 r mre cervical views Once, regardless f the number f cervical views it takes t cmplete the series Repeat X-rays The insurer wn t pay fr excessive r unnecessary X-rays. Repeat r serial X-rays may be perfrmed nly upn adequate clinical justificatin t cnfirm changes in the accepted cnditin(s). Dcumented changes in bjective findings r subjective cmplaints must supprt the need. CPT cdes and descriptins nly are 2011 American Medical Assciatin 26-11

12 Payment Plicies Chapter 26: R adilgy S ervices Links : R elated tpics If yu re lking fr mre infrmatin abut Then g here: Administrative rules Washingtn Administrative Cde (WAC) : (Washingtn state laws) fr X- ray custdy requirements WAC (1): Becming an L&I Prvider Billing instructins and frms L&I s website: ult.asp Chapter 2: Infrmatin fr All Prviders Payment plicies fr surgery Chapter 29: Surgery Services Prfessinal Services Fee Schedules L&I s website: hedules/2012fs/fsall.xls Need mre help? Call L&I s Prvider Htline at CPT cdes and descriptins nly are 2011 American Medical Assciatin