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Notification


Notification Issue Date:



Claim Payment Policy


Title:Radiologic Guidance of a Procedure

Policy #:00.10.36p

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

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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, radiologic guidance of a procedure is covered under the medical benefits of the Company's products.

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.



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: 00.01.25ar:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

 Policy: 03.00.20i:Modifiers 26 (Professional Component) and TC (Technical Component)

 Policy: 07.05.06f:Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies

 Policy: 11.02.10m:Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms

 Policy: 11.02.12i:Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery

 Policy: 11.02.17f:Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions

 Policy: 11.06.04k:Uterine Artery Embolization

 Policy: 11.11.01i:Evaluation and Treatment of Erectile Dysfunction (ED)

 Policy: 11.14.10q:Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty

 Policy: 11.15.09l:Denervation of the Spinal Nerves for Chronic Pain

 Policy: 12.01.01ar:Experimental/Investigational Services

Policy History

REVISIONS FROM 00.10.36p:
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 00.10.36o:
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


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/03/2019
Version Reissued Date: N/A

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