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

X-rays Associated with Fractures in the Office Setting

Notification Issue Date:

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.

Title:

X-rays Associated with Fractures in the Office Setting

Policy #:

MA00.031e

Policy

This policy applies to professional providers billing professional or outpatient facility claims, for members enrolled in all Company products.

X-rays associated with fractures when performed by a hand surgeon, orthopedic surgeon, podiatrist, or sports medicine specialist in an office setting are eligible for fee-for-service reimbursement consideration by the Company when the x-ray is necessary for any of the following criteria:

To determine the immediate care of a member with a suspected acute fracture and to provide treatment of a confirmed fracture as appropriate. (e.g., setting and casting of the fracture).
To make an ongoing treatment decision for a confirmed fracture that will impact the immediate care of the member.

Refer to Attachment A for a list of procedure codes eligible for fee-for-service reimbursement consideration when billed by Hand Surgeons, Orthopedic Surgeons, Sports Medicine Specialists.
Refer to Attachment B for a list of procedure codes eligible for fee-for-service reimbursement consideration when billed by Podiatrists.

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

X-rays for follow-up care should be performed at the designated capitated radiology site when the specialist has ruled out a fracture.

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 Evidence of Coverage, x-rays associated with a fracture are covered under the medical benefits of the Company's Medicare Advantage products.

BILLING GUIDELINES

In geographic areas with a capitated radiology program, x-rays associated with a fracture performed in the office setting as identified in this policy are exceptions to the capitated program.

Professional providers should report the diagnosis code(s) that closely describe the sign(s) and/or symptom(s) associated with the suspected fracture for the initial office visit. Professional providers should report the diagnosis code for the confirmed fracture for ongoing treatments.

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 of a confirmed fracture when they are necessary to make immediate treatment decisions.

References

Company Benefit Contracts.

Company Provider Manuals.

Coding

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

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

7/19/2021

Version Issued Date:

7/19/2021

Version Reissued Date: