Notification



Notification Issue Date:



Claim Payment Policy


Title:Diagnostic Radiology Services Included in Capitation

Policy #:00.03.02y

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.

In specific regions of Pennsylvania (PA), primary care physicians (PCPs) are required to select a participating outpatient radiology site to provide most outpatient diagnostic radiology services to members on the PCP's HMO capitation panel. The selected radiology site (ie, facility, ancillary, or professional provider) is the designated source for outpatient diagnostic radiology services that are included in capitation.

The diagnostic radiology procedure codes listed in Attachment A are included in capitation as part of the Company's Capitated Outpatient Diagnostic Radiology Program (CODRP) for HMO and HMO-POS product members who utilize their referred benefit and meet all of the following requirements:
  • Are age 12 and older.
  • Are enrolled in a Commercial or Medicare Advantage HMO or HMO-POS product.
  • Choose a PCP in the following Philadelphia five-county area: Bucks, Chester, Delaware, Montgomery or Philadelphia.

When the member does not meet the above requirements (eg, members age 11 and under) covered outpatient diagnostic radiology services are eligible for reimbursement consideration on a fee-for-service basis.

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 physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, 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 made available to the Company upon request.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, outpatient diagnostic radiology services are covered under the medical benefits of the Company's products.

MANDATES

As mandated by the State of New Jersey, members enrolled in NJ Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) products may elect to use their in-network benefits to obtain outpatient diagnostic radiology services from a participating radiology provider other than the primary care physician’s (PCP’s) designated radiology provider. However, referral requirements apply.

BILLING GUIDELINES
  • There may be circumstances when a procedure that is included in capitation may be provided by and eligible for reimbursement to a provider other than the designated radiology provider. Providers should refer to the Company's Provider Manual and provider communications for the requirements of and exceptions to the Capitated Outpatient Diagnostic Radiology Program (CODRP).
  • Delaware (DE) HMO and HMO-POS products do not include a CODRP.
  • Effective July 1, 2012 Commercial members enrolled in HMO and HMO-POS products with a PCP in the following NJ counties: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Ocean or Salem no longer have a CODRP.
    • Refer to Attachment B for a list of procedure codes included in capitation prior to July 1, 2012.


Description

Diagnostic radiology is the use of imaging modalities (eg, x-ray, ultrasound) to obtain a diagnosis of a medical condition.

Capitation is the reimbursement that a participating facility, ancillary provider (eg, freestanding outpatient radiology site), or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for an Health Maintenance Organization Point-of-Service (HMO-POS) member who utilizes his/her referred benefit.
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 Attachment A for the list of codes for services included in capitation for Pennsylvania (PA) members.

Refer to Attachment B for the list of codes for services included in capitation for New Jersey (NJ) members.


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 for the list of codes for services included in capitation for Pennsylvania (PA) members.

Refer to Attachment B for the list of codes for services included in capitation for New Jersey (NJ) members.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Diagnostic Radiology Services Included in Capitation
Description: Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members

Attachment B: Diagnostic Radiology Services Included in Capitation
Description: Diagnostic Radiology Procedure Codes Included in Capitation for New Jersey (NJ) Commercial Health Maintenance Organization (HMO) Members



Policy History

00.03.02y:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT & HCPCS codes have been deleted from this policy: 0346T, 77058, 77059, 78270, 78271, 78272, C8904, C8907, C9744

The following CPT codes have been added to this policy: 0541T, 0542T, 76978, 76979, 76981, 76982, 76983, 77046, 77047, 77048, 77049

00.03.02x:
01/01/2018This policy has been identified for the CPT code update.

The following CPT codes have been added to this policy, effective 01/01/2018:
0482T, 71045, 71046, 71047, 71048, 74018, 74019, 74021

The following CPT codes has been deleted from this policy, effective 01/01/2018:
71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 74000, 74010, 74020, 78190

The following CPT codes have been revised in this policy, effective 01/01/2018:
76881, 76882


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


Version Effective Date: 01/01/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.