MA PPO

Radiologic Guidance of a Procedure
MA00.019f


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 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.

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.

Highmark Medicare Services. Medicare Part B Reference Manual. Chapter 22: Global surgery and related issues. [Highmark Medicare Services Web site]. 11/02/2010. Available at: https://www.highmarkmedicareservices.com/refman/chapter-22.html. Accessed February 28, 2011.


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


Coding and Billing Requirements



Policy History

1/1/2020
1/6/2020
MA00.019
Claim Payment Policy Bulletin
Medicare Advantage
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Yes