TECHNICAL, ADMINISTRATIVE AND PROFESSIONAL RADIOLOGY COMPONENTS

The professional component (see modifier -26) for radiological services is intended to cover professional services, when applicable, as listed below:

1. Determination of the problem, including interviewing the patient, obtaining the history and making appropriate physical examination to determine the method of performing the radiologic procedure.

2. Study and evaluation of results obtained in diagnostic or therapeutic procedures, interpretation of radiographs or radioisotope data estimation resultant from treatment.

3. Dictating report of examination or treatment.

4. Consultation with referring physician regarding results of diagnostic or therapeutic procedures.
The technical or administrative component (see modifier -TC) includes items such as: cost or charges for technologists, clerical staff, films, opaques, radioactive materials, chemicals, drugs or other materials, purchase, rental use or maintenance of space, equipment, telephone services or other facilities or supplies.

Certain radiological procedures require the performance of a medical or surgical procedure (eg, studies necessitating an injection of radiopaque media, fluoroscopy, consultation) which must be performed by the radiologist and is not separable into technical and professional components for billing purposes. In these instances, the total fee listed in the Medicine or Surgery Services Fee Schedule is applicable

GENERAL INSTRUCTIONS

Fees listed in the Radiology Fee Schedule represent maximum allowances for reimbursement purposes in the Medical Assistance Program and include the administrative, technical and professional components of the service provided.

Fees are to be considered as payment for the complete radiological procedure, unless otherwise indicated. In order to be paid for both the professional and the technical and administrative components of the radiology service, qualified practitioners who provide radiology services in their offices must perform the professional component of radiology services and own or directly lease the equipment and must supervise and control the radiology technician who performs the radiology procedures; or be the employees of physicians who own or directly lease the equipment and must supervise and control the radiology technician who performs the radiology procedures. NY Medicaid does not enroll offsite radiologists for the sole purpose of professional component billing.

Each State agency may determine, on an individual basis, fees for services or procedures not included in this fee schedule. Such fee determinations should be reported promptly to the Division of Health Care Financing of the State Department of Health for review by the Interdepartmental Committee on Health Economics for possible incorporation in the Radiology Fee Schedule.

Procedure code 76999 - Billing and payment Guide

Procedure code 76999 - there is no specific Procedure code for this service. Procedure code 76999 is for unlisted Ultrasound procedures.

When performed in a hospital setting for ventilated patients in the ICU or for Operative patients with a need for ultrasound diagnostic procedures, the professional service only are separately payable when billing using Procedure code 76999 with the modifier 26 to show professional component.

When we billing the claim as globally in hospital setting with code 76999, will be returned as unprocessable to the provider with a reason code such as 59 denotes "Payment adjusted because treatment was deemed by the payer to have been rendered in an appropriate or invalid place of service."

When service are billed in a hospital setting as technical services with the code 7699-TC, Medicare will denied the claim as reason code 58 and Remark code M77 "Missing/Incomplete/Invalid place of service."

When performed in an ambulatory surgery center (ASC), ultrasound diagnostic procedures are covered when performed by and entity other than the ASC if globally billed using 7699-TC and 76999-26 respectively.


Ultrasound diagnostic procedure progessional services billed using codes 76999, 76999-TC, 76999-26 are carried-priced.

Medicare carriers have been made aware that claims will be made and makes it clear that such claims have to be paid, although the level of payment is left to the carrier to determine. The use of an unlisted procedure code (76999) is unusual and may make the initial claims process a little more complicated than is normally the case. However, CMS has  instructed carriers to pay claims for physician services with respect to EDM under this code and for that reason 76999 is as valid as any other Procedure code.



How should the level of service be quantified?

CMS has not specified how to report the use of EDM in either the ICU or surgical setting. One option for billing the service is to claim one occurrence of 76999 each time a patient is hemodynamically assessed and optimized using EDM. For each optimization ‘cycle’ the physician is required to place and focus the esophageal probe, establish a base-line value for key hemodynamic parameters (for billing purposes ‘stroke volume’ should suffice) and then deliver serial boluses of intravenous fluid until the stroke volume value change is less than ten percent, indicating that the patient is optimized. A subsequent fall in stroke volume of greater than ten percent would trigger the next optimization cycle and a further claim under 76999. This approach may be used for patients in surgery or ICU.

How will claims for the use of EDM be processed?

The use of a miscellaneous code such as 76999 requires that the claim be manually processed. This will probably require a response to requests for supplemental information the first claims submitted.

POS - WHEN interpreation made outside US AND UNDER Arrangement in Hosp

B. Interpretation Provided Outside of the United States

Generally, Medicare will not pay for health care or supplies that are performed outside the United States (U.S.). The term “outside the U.S.” means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. See Pub. 100-02, chapter 16, section 60, for exceptions to the “outside the U.S.” exclusions.

Interpretation Provided Under Arrangement - To A Hospital

Separate TC and PC

If a diagnostic test which has a separate TC and PC is provided under arrangement to a hospital, the physician who reads the test can bill and be paid for the professional component. Both the technical and professional components of the test are also subject to the physician self-referral prohibition.

The appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the TC service. If the interpretation is performed in the physician’s office and the patient received the TC service in the provider-based outpatient hospital setting, the physician assigns POS code 22, for On Campus-Outpatient Hospital, or POS 19, for Off Campus-Outpatient Hospital, on the claim for the interpretation or PC.

Global Service

When a physician performs a diagnostic test under arrangement to a hospital and the test and the interpretation are not separately billable, the interpretation cannot be billed by the physician. In this scenario, the hospital is the only entity that can bill for the diagnostic test which encompasses the interpretation. There is no POS code for the interpretation since a physician claim is not generated.

D. Global Billing

Billing globally for services that are split into PC and TC components is only possible when the TC and the physician who provides the PC of the diagnostic service are furnished by the same physician or supplier entity and the PC and TC components are furnished within the same Medicare physician fee schedule payment locality. Merely applying the same POS code to the PC as that of the TC (as described in “A” above) does not permit global billing for any diagnostic procedure.

Compensation for Ultrasound Procedures - Payment policyt

Claims submitted for the global or technical component of certain ultrasound procedures when billed in combination with other ultrasound procedures for a single member within the same visit will be denied as they are considered to be included within another procedure.

In these instances, Tufts Health Plan will compensate the imaging service with the highest allowable compensation amount at 100% of the Tufts Health Plan compensation rate and subsequent procedure(s) that are considered to be included in the other ultrasound procedure will be denied.

Professional/Technical Components

**Tufts Health Plan does not add or remove modifiers 26 (professional component) or TC (technical component) to procedure codes requiring the presence or absence of those modifiers in order to apply existing professional and technical component edits. Tufts Health Plan will not compensate for procedure codes requiring modifiers 26 and/or TC if they are not billed in accordance with the current payment policy.

**Tufts Health Plan will not compensate for diagnostic tests and radiology services having a professional component performed in a home, assisted living facility, nursing facility or skilled nursing facility if those services are billed without modifier 26 to indicate the professional component and transportation of portable x-ray equipment (R0070-R0075) is not also submitted.

**Tufts Health Plan will not compensate for a procedure code requiring modifier TC if a facility bills without modifier TC.

COMPENSATION/REIMBURSEMENT for Diagnostic and Radiology Services

Providers are compensated according to Tufts Health Plan network contracted rates regardless of the address where the service is rendered. Claims are subject to payment edits that are updated at regular intervals and generally based on Centers for Medicare & Medicaid Services (CMS), specialty society guidelines, drug manufacturers’ package label inserts and National Correct Coding Initiative (CCI).

Procedure Code Guidelines

Tufts Health Plan will not compensate for inappropriately-coded services, based on Procedure  code /HCPCS Procedure Code Guidelines.

Compensation for providers who are not radiologists is based on privileging requirements. Claims received for services that do not meet privileging requirements will be denied and the member is not responsible for payment. Tufts Health Plan does not compensate for any component of MRI/MRA, CT/CTA, and PET services performed by a participating physician who is not credentialed by Tufts Health Plan as a radiologist.

Diagnostic and Radiology Services
Tufts Health Plan will not compensate a diagnostic test or radiology service billed with modifier 26 (professional component) and modifier TC (technical component) if the technical and professional components of the service are performed by the same provider billed on the same or different claim on the same date of service. According to the AMA Principles of Procedure Coding, it is not appropriate to report the components of the professional and technical service separately.

Tufts Health Plan will not compensate for the professional component (modifier 26) or consultation (76140) when billed with a radiology procedure performed in the office setting and in conjunction with an E&M service.

Tufts Health Plan will not compensate professional services when billed by a provider other than an anesthesiologist, neurologist, physical medicine specialist, radiologist or radiation oncologist in the inpatient, outpatient or ER setting.

Compensation/Reimbursement for Multiple Imaging Procedures

A reduction in payment is applied to claims submitted for the technical (performance of the imaging service) or global (performance and interpretation) component of an imaging procedure when certain procedure code combinations are billed for a single member within the same visit.

In these instances, Tufts Health Plan will compensate the imaging service with the higher allowable compensation amount at 100% of the Tufts Health Plan compensation rate and subsequent procedure(s) that are subject to reduction logic will be compensated at 50% of the Tufts Health Plan compensation rate.