MA PPO

X-rays Associated with Fractures in the Office Setting
MA00.031d


Policy

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

The Company will provide fee-for-service reimbursement for x-rays associated with fractures that are performed in the hand surgeon's, orthopedic surgeon's, podiatrist's, or sports medicine specialist's office when all of the following criteria are met:
  • The x-ray is necessary for either of the following:
    • To determine the immediate care of a member with a suspected acute fracture.
    • To make an ongoing treatment decision for a confirmed fracture that will impact the immediate care of the member.
  • The specialist's routine practice must include the setting/casting of fractures.
  • The procedure code represents the x-ray as described in Attachment A (codes eligible for reimbursement when billed by hand surgeons, orthopedic surgeons, or sports medicine specialists), or in Attachment B (codes eligible for reimbursement when billed by podiatrists).
  • For the initial visit, professional providers should report the diagnosis code representative of the suspected fracture.
OR
  • For determining ongoing treatment, professional providers should report the diagnosis code representative of the confirmed fracture.

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

When a fracture has been ruled out, follow-up x-rays should be obtained at the designated capitated site.

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 or podiatry program, x-rays associated with a fracture performed in the office setting are exceptions to the capitated program.

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 when they are necessary to make immediate treatment decisions.

References


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


Coding and Billing Requirements



Policy History

12/1/2017
12/1/2017
MA00.031
Claim Payment Policy Bulletin
Medicare Advantage
{"1683":{"Id":1683,"MPAttachmentLetter":"A","Title":"Codes eligible for reimbursement when billed by Hand Surgeons, Orthopedic Surgeons, or Sports Medicine Specialists","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"16177F583FC4A41685258275004FF972"},"1684":{"Id":1684,"MPAttachmentLetter":"B","Title":"Codes eligible for reimbursement when billed by Podiatrists","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"614E1F051BE33B0085258275004FFA3C"},}
Yes