Radilogy claim submission - specific instruction for paper and electronic claims

Specific Instructions for Filing Claims Subject to Anti-Markup Limitation
Providers may not submit a global billing or total component code on paper or electronic claims when one component of the service is subject to the anti-markup limitation. To determine the correct payment jurisdiction and price services correctly, the technical and professional components of the service must be submitted on separate detail lines or on separate claims, depending on how the claim is filed (paper or electronic).

Paper Claims: The technical component and the professional component must be submitted on separate claim forms. The physical address of the location where the specific test component was rendered should be entered in Item 32, along with the NPI of the performing physician. If the performing physician is enrolled with a different B/MAC, the NPI of the billing entity must be reported in item 32.

Electronic Claims: The services may be submitted on the same claim, but on separate detail lines. The corresponding service facility location and physical address must be entered for each service at the line level.

* The Medicare Physician Fee Schedule National Abstract File for Diagnostic Tests/Interpretations subject to the anti-markup limitation will be used to price all claims for these diagnostic services based on the ZIP code of the location where the service was rendered, including those submitted by physicians for diagnostic services subject to the anti-markup limitation performed outside the local carrier’s jurisdiction.

* Physicians and suppliers must report the rendering physician’s/supplier’s information and the location where the service was rendered on all claims subject to the anti-markup limitation, including those performed outside the local carrier’s jurisdiction.

* Physicians/suppliers are not to report the National Provider Identifier (NPI) of the out-of-jurisdiction performing physician/supplier when submitting a claim for a diagnostic service subject to the anti-markup limitation and acquired outside of their local carrier’s/Medicare Administration Contractor’s (MAC’s) jurisdiction. In the case of the performing physician/supplier being in another B/MAC jurisdiction, the billing physician/supplier must submit its own NPI in Item 32.

* Physicians and suppliers may only submit claims for tests/interpretations when these services are performed within the United States. (In this context, the term “United States” means the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa.)

TC component - Multiple procedure reduction rule

Multiple Procedure Reduction on the TC of Certain Diagnostic Imaging Procedures

Effective January 1, 2006, a multiple procedure reduction of the TC of certain diagnostic imaging procedures applies. The reduction applies to TC-only services and the TC portion of global services for the procedures with a diagnostic imaging indicator as shown on the Medicare Fee Schedule. The reduction does not apply to Professional Component (PC) services. Full payment will be allowed for the highest-priced procedure and payment at 50 percent for each additional procedure when performed during the same session on the same day.

Note: Prior to July 1, 2010, the reduction was 25 percent for the additional procedures.

For dates of service prior to January 1, 2011, the reduction applies only to procedures to contiguous body areas (i.e., within a family of codes, not across families) that are provided in one session. For example, the reduction would not apply to an MRI of the brain (Procedure code 70552) in code family 5 when performed during the same (single) session, on the same day as an MRI of the neck and spine (Procedure code 72142) in code family 6.

The 11 families of imaging procedures are arranged by imaging modality:

* Ultrasound, Computed Tomography (CT) and Computed Tomographic Angiography (CTA).
* MRI and Magnetic Resonance Angiography (MRA).
* Contiguous area (for example: CT and CTA of Chest/Thorax/Abdomen/Pelvis).

To determine which family the imaging procedure belongs to, refer to the Diagnostic Imaging Indicator on the Medicare Fee Schedule on the TrailBlazer Health Enterprises® Web site.

CMS considers a single session to be one encounter where a patient could receive one or more radiological studies. If more than one of the imaging services in a single family is provided to the patient during one encounter, then this would constitute a single session and the lower-priced procedure(s) would be reduced.

There is no need to report the 51 modifier on your claim. Medicare will append the 51 modifier to the appropriate service during claims processing.

On the other hand, if a patient has a separate encounter on the same day for a medically necessary reason and receives a second imaging service from the same family, then CMS considers these multiple studies in the same family on the same day to be provided in separate sessions.

In the latter case, CMS has established that the physician should use modifier 59 to indicate multiple sessions, and that the multiple procedure reduction does not apply.

Effective January 1, 2011, per Change Request (CR) 6993, the 11 families of codes are being consolidated into a single family.

Currently, the multiple procedure reduction on diagnostic imaging services applies to contiguous body parts, i.e., within a family of codes, not across families. With the consolidation of the 11 families down to one family of codes, the reductions apply when two or more services on the list are furnished to the same patient in a single session. The complete list of codes is listed in the CR linked below.

Change Request:
http://www.cms.gov/transmittals/downloads/R738OTN.pdf

MLN Matters Article:
http://www.cms.gov/MLNMattersArticles/downloads/MM6993.pdf

Copayment and timelimit for radiology billing

Cost Sharing (Copayment)

Copayment amount does not apply to services provided by Independent Radiology providers.

Time Limit for Filing Claims.

Medicaid requires all claims for Independent Radiology providers to be filed within one year of the date of service. Refer to Section 5.1.4, Filing Limits, for more information regarding timely filing limits and exceptions

Diagnosis Codes

For dates of service 01/01/99 and after, valid diagnosis codes are required.
The International Classification of Diseases - 9th Revision - Clinical
Modification (ICD-9-CM) manual lists Medicaid required diagnosis codes.

These manuals may be obtained by contacting the American Medical
Association, P. O. Box 10950, Chicago, IL 60610.

For dates of service prior to 01/01/99, Independent Radiology providers are
not required to provide valid diagnosis codes. Providers must bill diagnosis
code V729 on hard copy and electronically submitted claims.

NOTE
ICD-9 diagnosis codes must be listed to the highest number of digits
possible (3, 4, or 5 digits). Do not use decimal points in the diagnosis
code field.

Radiology billing for two interpretations, multiple claim and for repeated x-ray

Multiple Claims

Medi-Cal reimburses for only one interpretation of an individual X-ray procedure performed on a patient.  Reimbursement is allowed for only one technical component (modifier TC) and only one professional component (modifier 26) for each individual X-ray when billed by any providers, for the same recipient and date of service.  When multiple claims for the professional and/or technical component of an individual X-ray procedure are billed by different providers for the same recipient and date of service, only the first successfully adjudicated claim is reimbursed.

Two Interpretations

Two interpretations of the same X-ray are reimbursable only under unusual circumstances (for example, a second interpretation of a questionable finding by another physician).  A second interpretation or “proof reading” by a second physician of an X-ray is considered a quality control activity and is not separately reimbursable.


Repeated X-Ray

If the same X-ray has been repeated by any provider for the same recipient and date of service, justification for the repeat X-ray must be included in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim, or on an attachment.


Modifier 26/ZS

The professional component (modifiers 26 and ZS) of radiology Procedure-4 codes 77261 – 79999 is not reimbursable when billed with an E&M procedure (other than 99211) when performed by the same provider, for the same recipient, on the same date of service.

Is CLIA number required for Radiology billing

CLIA Number:  Billing for Radiology   

Providers billing for Procedure-4 radiology codes 78110, 78111,  78120 – 78122, 78130, 78191 and 78270 – 78272 must be Clinical Laboratory Improvement Amendments (CLIA)-certified.  Laboratories that do not perform proficiency testing verification for Radiobioassay must have a system for verifying the accuracy and reliability of test results at least twice per year.  Questions regarding state and federal requirements for proficiency testing should be directed to the California Department of Public Health (CDPH) Laboratory Field Services at (510) 620-3800.

Rendering Provider Number

The rendering provider number is required on claims for services billed with Procedure-4 codes 70010 – 79999.  However, the provider number of the attending/referring/prescribing physician, if different from the rendering provider, continues to be required on the claim for these procedures.

    Radiologists requesting reimbursement for procedures outside these code ranges must meet the rendering provider number requirements.