Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Radiologic Guidance of a Procedure
Policy #:MA00.019f

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Radiologic guidance and/or supervision and interpretation of a procedure that is performed in conjunction with a covered procedure is eligible for separate reimbursement consideration by the Company.
  • Refer to Attachment A for a list of radiologic guidance and/or supervision and interpretation procedure codes. Not all services listed are eligible in all settings and/or to all providers.
  • Radiologic guidance and/or supervision and interpretation are considered to be physician (ie, medical doctor [MD], doctor of osteopathy [DO]) services only.
  • When the same provider performs and reports both the radiologic and the diagnostic or therapeutic procedures, both procedures are eligible for reimbursement consideration to the provider. However, all of the following policy requirements must be met:
    • Both the radiologic guidance and/or supervision and interpretation service and the procedure for which it is performed must be covered for the radiologic guidance and/or supervision and interpretation to be eligible for separate reimbursement consideration.
    • Documentation in the medical record must reflect the radiologic guidance and/or supervision and interpretation procedure(s) performed and must be available to the Company upon request. However, providers should not submit medical records to the Company unless requested.
  • Radiologic guidance and/or supervision and interpretation services may have professional and technical components.

Facility reimbursement for the technical component of the radiologic guidance of a procedure is in accordance with the individual facility's contract.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, radiologic guidance of a procedure is covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this policy are met.

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

CAPITATION

In geographic areas with a Capitated Outpatient Diagnostic Radiology Program (CODRP), radiologic guidance and/or supervision and interpretation of a procedure are not included in capitation.

Description

Radiologic guidance is the use of radiologic technologies (eg, ultrasound, fluoroscopy, computed tomography) to direct or guide the placement and/or removal of material (eg, catheters, needles) or as an adjunct to or in combination with another diagnostic or therapeutic procedure (eg, endoscope, catheter, graft, shunt or stent placement, biopsy). Radiologic guidance and/or supervision and interpretation is performed by either the same professional provider who performs the surgical procedure or by a different professional provider.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 13: Radiology Services and Other Diagnostic Procedures. Supervision and Interpretation (S&I) Codes and Interventional Radiology. 80.0. [CMS Web site]. 07/09/10. Available at: http://www.cms.gov/manuals/downloads/clm104c13.pdf. Accessed February 28, 2011.

Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Version 16.3. Chapter IX, Radiology Services. Effective 10/01/10. [CMC Web site]. Available at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage (zip folder document: CHAP9-CPTcodes70000-79999_08312010.pdf). Accessed February 28, 2011.

Company Provider Contracts.

Highmark Medicare Services. Medicare Part B Reference Manual. Chapter 22: Global surgery and related issues. [Highmark Medicare Services Web site]. 11/02/2010. Available at: https://www.highmarkmedicareservices.com/refman/chapter-22.html. Accessed February 28, 2011.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachment A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Radiologic Guidance of a Procedure
Description: Radiologic Guidance and Supervision and Interpretation Procedure Codes







Policy History

REVISIONS FROM MA00.019f:
01/01/2020This policy has been identified and updated for the CPT code update effective 01/01/2020.

The following CPT code has been termed from this policy: 76930.

REVISIONS FROM MA00.019e:
01/01/2019This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT code has been termed from the policy:

76001: Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT narratives have been revised in this policy:

74485

FROM: Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation

TO: Dilation of ureter(s) or urethra, radiological supervision and interpretation

77021

FROM: Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

TO: Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

77022

FROM: Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation

TO: Magnetic resonance imaging guidance for, and monitoring of, parenchymal tissue ablation

77387

FROM: Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed
TO: Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed


REVISIONS FROM MA00.019d:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT codes have been termed from this policy: 75658, 75952, 75953 and 75954

REVISIONS FROM MA00.019c:
01/01/2017This policy has been identified for the CPT code update, effective 01/01/2017.

The following CPT codes have been termed from this policy:

0291T, 0292T, 75791, 75962, 75964, 75966, 75968, 75978

The following CPT / HCPCS code has been added to this policy:

92242

The following CPT narratives have been revised in this policy:

77002:
FROM: Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)
TO: Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)

77003:
FROM: Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)
TO: Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure)

92978:
FROM: Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (list separately in addition to code for primary procedure)
TO: Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure)

92979:
FROM: Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (list separately in addition to code for primary procedure)
TO: Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure)

REVISIONS FROM MA00.019b:
01/01/2016This policy has been identified for the CPT code update, effective 12/31/2015.

The following CPT codes have been deleted from this policy:
70373, 74305, 74320, 74327, 74475, 74480, 75896, 75945, 75946, 75980, 75982

REVISIONS FROM MA00.019a:
02/09/2015This policy has been identified for the CPT code update, effective 01/02/2015

The following codes have been deleted from this policy:
72291, 72292, 76950, 77421

The following codes have been added to this policy:
77387, G6001, G6002

The following codes have been revised to this policy:
0075T, 0076T

REVISIONS FROM MA00.019:
01/01/2015This is a new policy.




Version Effective Date: 01/01/2020
Version Issued Date: 01/06/2020
Version Reissued Date: N/A