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(no longer valid codes) and removed from this policy: 0080T, 0081T, 75724, 75940.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

Version Effective Date:

8/1/2022

Version Issued Date: