Notification

X-rays Associated with Fractures in the Office Setting


Notification Issue Date: 11/01/2017

This policy becomes effective 12/01/2017.

This policy has been expanded to include Physician Assistants (PAs) to be eligible to perform services in a specialty group.



Claim Payment Policy


Title:X-rays Associated with Fractures in the Office Setting

Policy #:00.03.09d

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

The Company will provide fee-for-service reimbursement for x-rays associated with fractures that are performed in the hand surgeon's, orthopedic surgeon's, podiatrist's, or sports medicine specialist's office when all of the following criteria are met:
  • The x-ray is necessary for either of the following:
    • To determine the immediate care of a member with a suspected acute fracture.
    • To make an ongoing treatment decision for a confirmed fracture that will impact the immediate care of the member.
  • The specialist's routine practice must include the setting/casting of fractures.
  • The procedure code represents the x-ray as described in Attachment A (codes eligible for reimbursement when billed by hand surgeons, orthopedic surgeons, sports medicine specialists), or in Attachment B (codes eligible for reimbursement when billed by podiatrists).
  • For the initial visit, professional providers should report the diagnosis code representative of the suspected fracture.
OR
  • For determining ongoing treatment, professional providers should report the diagnosis code representative of the confirmed fracture.

X-rays associated with a fracture or a suspected fracture that do not meet the above criteria should be rendered at the member's primary care provider's (PCP's) designated radiology site.

When a fracture has been ruled out, follow-up x-rays should be obtained at the designated capitated site.

For members enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) products that require referrals, x-rays associated with a fracture or a suspected fracture are covered under the fracture referral to the specialist. A separate referral for services provided by the specialist is not required.

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 professional provider'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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, x-rays associated with a fracture are covered under the medical benefits of the Company's products.

BILLING GUIDELINES

In geographic areas with a capitated radiology or podiatry program, x-rays associated with a fracture performed in the office setting are exceptions to the capitated program.

Description

Generally, members enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) products using their referred benefit are required to obtain outpatient diagnostic radiology services at their primary care provider's (PCP's) designated radiology site.

There may be circumstances when it is medically necessary for x-rays associated with a fracture to be performed in the specialist's office. X-rays associated with fracture care may include the initial x-ray to diagnose a fracture and subsequent x-rays when they are necessary to make immediate treatment decisions.
References


Company Benefit Contracts.

Company Provider Manuals.




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 the following Attachments for a list of eligible CPT codes:


Attachment A: Codes eligible for reimbursement when billed by Hand Surgeons, Orthopedic Surgeons, or Sports Medicine Specialists

Attachment B: Codes eligible for reimbursement when billed by Podiatrists



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)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: X-rays Associated with Fractures in the Office Setting
Description: Codes Eligible for Reimbursement by Hand Surgeons, Orthopedic Surgeons, or Sports Medicine Specialists

Attachment B: X-rays Associated with Fractures in the Office Setting
Description: Codes Eligible for Reimbursement by Podiatrists



Policy History

00.03.09d
12/01/2017This policy becomes effective 12/01/2017.
This policy has been expanded to include Physician Assistants (PAs) to be eligible to perform services in a specialty group.

00.03.09c
08/01/2017Revised policy number 00.03.09c was issued as a result of a provider networking initiative. The adoptable source for this policy is Provider Contracting.
Certified registered nurse practitioner (CRNP) practicing within the scope of their license may be eligible to perform X-rays associated with fractures in the surgeon's, orthopedic surgeon's, podiatrist's, or sports medicine speciality group. To determine when the CRNP is eligible, see the necessary criteria in the Policy Section of this policy.
The following language was added to the Policy Section of this policy:
This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

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 professional provider'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.

00.03.09b
01/01/2016This policy has been identified for the CPT code update, effective 01/01/2016.
The following CPT codes have been added to this policy: 73551, 73552

00.03.09a
10/01/2015Revised policy number 00.03.09 was issued as a result of annual policy review and coding update. The policy was updated to be consistent with current template wording and format.
Effective 10/01/2015 and after, due to the large volume of ICD-10 codes, diagnosis codes will no longer be included in policy as maintenance would be unmanageable.

00.03.09
05/27/2011Claim Payment Policy # 00.03.09 has been developed for external disclosure as a result of multiple inquires to Network Services from the Orthopedic provider network.
The intent of the policy is to disclose the radiology services that are eligible above capitation when provided in the office setting by a Orthopedic Surgeon, Hand Surgeon, Sports Medicine Specialist or a Podiatrist, when the service is provided as a result of a suspected or confirmed fracture.
This policy will replace CPP # 11.14.16d, X-rays Associated with Fracture Care When Performed in the Office Setting.
Version Effective Date: 12/01/2017
Version Issued Date: 12/01/2017
Version Reissued Date: N/A

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