Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

Radiologic Guidance and/or Supervision and Interpretation of a Procedure

Notification Issue Date:

This policy will become effective 10/12/2020. The policy title has been changed to Radiologic Guidance and/or Supervision and Interpretation of a Procedure.

The Company’s reimbursement position has clarified our continued position that Radiologic Guidance and/or Supervision and Interpretation when performed in conjunction with non-covered services is not covered.

The following CPT codes have been

termed

(no longer valid codes) and removed from this policy: 0080T, 0081T, 75724, 75940.

The following CPT codes have been

removed

from this policy: 76936, G0278.

Title:

Radiologic Guidance and/or Supervision and Interpretation of a Procedure

Policy #:

MA00.019j

Policy

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.

Radiologic guidance and/or supervision and interpretation that is performed in conjunction with a covered procedure is eligible for separate reimbursement consideration by the Company.

Radiologic guidance and/or supervision and interpretation are considered to be physician (i.e., medical doctor [MD], doctor of osteopathy [DO]) services only).
When the same provider performs and reports both the radiologic guidance and/or supervision and interpretation and the diagnostic or therapeutic procedure(s), both procedures are eligible for separate reimbursement consideration to the provider. However, all of the following 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.
- Documentation in the medical record must reflect the radiologic guidance and/or supervision, and interpretation service was performed by the same provider.
Radiologic guidance and/or supervision and interpretation services may have professional and technical components.
- For information regarding the appropriate use of professional and technical component modifiers, please refer to claim payment policy MA03.011.

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

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. When radiologic guidance and/or supervision and interpretation is performed in conjunction with a non-covered procedure, it is not eligible for reimbursement.

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 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.

Description

Radiologic guidance is the use of radiologic technologies (e.g., ultrasound, fluoroscopy, computed tomography) to direct or guide the placement and/or removal of material (e.g., catheters, needles) or as an adjunct to or in combination with another diagnostic or therapeutic procedure (e.g., 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 June 20, 2022.

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 June 20, 2022.

Company Provider Manuals.

Coding

CPT Procedure Code Number(s)

Refer to Attachment A.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Refer to Attachment A.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.019j:

08/01/2022

This policy will become effective 08/01/2022 to communicate the Company’s continuing position on Radiologic Guidance and Supervision and Interpretation Procedure Codes.

The following CPT codes have been added to Attachment A of this policy:
76376, 76377, 76977

The following CPT code narratives have been revised in Attachment A of this policy:
72285, 72295, 74340

Revisions From MA00.019i:

01/01/2022

This policy has been identified and updated for the CPT code update effective 01/01/2022.

The following CPT code has been deleted from Attachment A of this policy:
72275

Revisions From MA00.019h:

01/01/2021

This policy has been identified and updated for the CPT code update effective 01/01/2021.

The following CPT code narrative has been revised in Attachment A of this policy:
74425

Revisions From MA00.019g:

10/12/2020

This policy will become effective 10/12/2020. The policy title has been changed to Radiologic Guidance and/or Supervision and Interpretation of a Procedure.

The Company’s reimbursement position has clarified our continued position that Radiologic Guidance and/or Supervision and Interpretation when performed in conjunction with non-covered services is not covered.

The following CPT codes have been termed (no longer valid codes) and removed from this policy: 0080T, 0081T, 75724, 75940.

The following CPT codes have been removed from this policy: 76936, G0278.

Revisions From MA00.019f:

01/01/2020

This 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:

01/01/2019

This 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:

01/01/2018

This 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:

01/01/2017

This 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:

01/01/2016

This 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:

02/09/2015

This 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:

01/01/2015

This is a new policy.

Version Effective Date:

8/1/2022

Version Issued Date: