(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 13 - Radiology Services and Other Diagnostic Procedures   Table of Contents  (Rev. 12364, 11- 16-23)  Transmittals for Chapter 13  10 - ICD Coding for Diagnostic Tests  10.1 -  Billing Part B Radiology Services and Other Diagnostic Procedures  20 - Payment Conditions for Radiology Services  20.1 -  Professional Component (PC)  20.2 -  Technical Component (TC)  20.2.1 -  Hospital and Skilled Nursing Facility (SNF) Patients  20.2.2 -  Services Not Furnished in Hospitals  20.2.3 -  Services Furnished in Leased Departments  20.2.4  Services That Do Not Meet the National Electrical Manufacturers Association (NEMA) Standard XR -29-2013 20.2.5 -  Special Rule to Incentivize Transition from Traditional X -Ray Imaging to Digital Radiography  20.2.5.1 -  Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs), and Medicare Summary Notice (MSN)    20.2.6 - Special Rule to Incentivize Transition from X -rays taken using Computed Radiography to Digital Radiography  30 - Computerized Axial Tomography (CT) Procedures  30.1 -  Low Osmolar Contrast Media (LOCM) (HCPCS Codes Q9945- Q9951)  30.1.1 -  Payment Criteria  30.1.2 -  Payment Level  30.1.3 -  SNF Billing and A/B MAC (A)  Payment for Contrast Material Other Than Low Osmolar Contrast Material (LOCM) (Radiology)  30.1.3.1 -  A/B MAC (A) Payment for Low Osmolar Contrast Material (LOCM) (Radiology)  40 - Magnetic Resonance Imaging (MRI) Procedures  40.1  Magnetic Resonance Angiography (MRA)  40.1.1 -  Magnetic Resonance Angiography (MRA) Coverage Summary  40.1.2 -  HCPCS Coding Requirements  40.1.3 -  Special Billing Instructions for RHCs and FQHCs  40.1.4 -  Payment Requirements  40.2 -  Medicare Summary Notices (MSN), Reason Codes, and Remark Codes  50 - Nuclear Medicine (CPT 78000 -  79999)  50.1 -  Payments for Radionuclides  50.2 -  Stressing Agent  50.2.1 - A/B MAC (A) Payment for IV Persantine  50.2.2 -  A/B MAC (A) Payment for Adenosine  50.3 -  Application of Multiple Procedure Policy (CPT Modifier  -51) 50.4 -  Generation and Interpretation of Automated Data  60 - Positron Emission Tomography (PET) Scans - General Information  60.1 -  Billing Instructions  60.2 -  Use of Gamma Camera and Full and Partial Ring PET Scanners for PET Scans  60.2.1 -  Coverage for Myocardial Viability  60.3 -  PET Scan Qualifying Conditions and HCPCS Code Chart  60.3.1 -  Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005  60.3.2 -  Tracer Codes Required for Positron Emission Tomography (PET) Scans  60.3.3 -  Denial Messages for Noncovered PET Services  60.4 -  PET Scans for Imaging of the Perfusion of the Heart Using Rubidium 82 (Rb 82)  60.5 -  Expanded Coverage of PET Scans for Solitary Pulmonary Nodules (SPNs)  60.6 -  Expanded Coverage of PET Scans Effective for Services on or After July 1, 1999 60.7 -  Expanded Coverage of PET Scans Effective for Services on or After July 1, 2001 60.8 -  Expanded Coverage of PET Scans for Breast Cancer Effective for Dates of Service on or After October 1, 2002  60.9 -  Coverage of PET Scans for Myocardial Viability 60.10 -  Coverage of PET Scans for Thyroid Cancer  60.11  - Coverage of PET Scans for Perfusion of the Heart Using Ammonia N -13 60.12 -  Coverage for PET Scans for Dementia and Neurodegenerative Diseases  60.13 -  Billing Requirements for PET Scans for Specific Indications of Cervical Cancer for Services Performed on or After January 28, 2005  60.14 -  Billing Requirements for PET Scans for Non- Covered Indications  60.15 -  Billing Requirements for CMS -  Approved Clinical Trials and Coverage With Evidence Development Claims for PET Scans for Neurodegenerative Diseases, Previously Specified Cancer Indications, and All Other Cancer Indications Not Previously Specified 60.16  Billing and Coverage Changes for PET Scans  60.17  Billing and Coverage for PET Scans for Cervical Cancer Effective for Services on or After November 10, 2009 60.18  Billing and Coverage Changes for PET (NaF -18) Scans to Identify Bone Metastasis of Cancer Effective for Claims With Dates of Services on or After February 26, 2010 60.19  Local Coverage Determination for PET Using New, Proprietary Radiopharmaceuticals for their FDA -Approved Labeled Indications for Oncologic Imaging Only  70 - Radiation Oncology (Therapeutic Radiology)  70.1 -  Weekly Radiation Therapy Management (CPT 77419 -  77430)  70.2 -  Services Bundled Into Treatment Management Codes  70.3 -  Radiation Treatment Delivery (CPT 77401 -  77417)  70.4 -  Clinical Brachytherapy (CPT Codes 77750 -  77799)  70.5 -  Radiation Physics Services (CPT Codes 77300 -  77399)  80 - Supervision and Interpretation (S&I) Codes and Interventional Radiology  80.1 -  Physician Presence 80.2 -  Multiple Procedure Reduction 90 - Services of Portable X -Ray Suppliers  90.1 -  Professional Component  90.2 -  Technical Component  90.3 -  Transportation Component (HCPCS Codes R0070 -  R0076)  90.4 -  Set-Up Component (HCPCS Code Q0092)  90.5 -  Transportation of Equipment Billed by a SNF to a MAC  100 -  Interpretation of Diagnostic Tests  100.1 -  X-rays and EKGs Furnished to Emergency Room Patients  110 -  Special Billing Instructions for Claims Submitted to A/B MACs (A)  110.1 -  Aborted Procedure  110.2 -  Combined Procedures (Radiology)  110.3 -  Payment for Radiopharmaceuticals  120 -  Radiology or Other Diagnostic Unlisted Service or Procedure Billing Instructions for A/B MAC (A) Claims  130 -  EMC Formats  140 -  Bone Mass Measurements  (BMMs)  140.1 -  Payment Methodology and HCPCS Coding 140.2 -  Denial Messages for Noncovered Bone Mass Measurements  140.4 -  Advance Beneficiary Notices (ABNs)  150 -  Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests  10 - ICD Coding for Diagnostic Tests  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  The ICD Coding Guidelines for Outpatient Services (hospital -based and physician office) have instructed physicians to report diagnoses based on test results.  Instructions and examples for coding specialists, contractors, physicians, hospitals, and other health care providers to use in determining the use of ICD codes for coding diagnostic test results is found in chapter 23.   10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures  (Rev. 1, 10- 01-03)  Acceptable HCPCS codes for radiology and other diagnostic services are taken primarily from the CPT -4 portion of HCPCS.  Payment is the lower of the charge or the Medicare physician fee schedule amount. Deductible and coinsurance apply, and coinsurance is based on the allowed amount .  For claims to A/B MACs (A) or (HHH), revenue codes, HCPCS code, line item dates of service, units, and applicable HCPCS modifiers are required.  Charges must be reported by HCPCS code.  If the same revenue code applies to two or more HCPCS codes, providers  should repeat the revenue code and show the line item date of service, units, and charge for each HCPCS code on a separate line.   20 - Payment Conditions for Radiology Services  (Rev. 1, 10- 01-03) B3-15022  20.1 - Professional Component (PC)  (Rev. 1, 10- 01-03)  A/B MACs (B) must pay for the PC of radiology services furnished by a physician to an individual patient in all settings under the fee schedule for physician services regardless of the specialty of the physician who performs the service.  For services furnished to hospital patients, A/B MACs (B) pay only if the services meet the conditions for fee schedule payment and are identifiable, direct, and discrete diagnostic or therapeutic services to an individual patient, such as an interpretation of diagnostic procedures and the PC of therapeutic procedures.  The interpretation of a diagnostic procedure includes a written report.   20.2 - Technical Component (TC)  (Rev. 1, 10- 01-03)  20.2.1 - Hospital and Skilled Nursing Facility (SNF) Patients  (Rev. 1782; Issued:  07- 30-09; Effective Date:  07 -01-09; Implementation Date:  07- 06-09)  A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service.   AB MACs (A) include the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in the prospective payment system (PPS) payment to hospitals.  Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay.  CWF performs reject edits to incoming claims from suppliers of radiology services.   Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares the period between the hospital inpatient admission and discharge dates to the line item service date on a line item TC of a radiology service billed by a s upplier.  The CWF will generate an unsolicited response when the line item service date falls within the admission and discharge dates of the hospital inpatient claim.   Upon receipt of an unsolicited response, the A/B MAC (B) will adjust the TC of the radiology service and recoup the payment.   For CAHs, payment to the CAH for inpatients is made at 101 percent of reasonable cost.   Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are submitted to the AB MAC (A).  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for radiology services.   As a result of SNF Consolidated Billing (Section 4432(b) of the Balanced Budget Act (BBA) of 1997), A/B MACs (B) may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay.  The SNF must  bill radiology services furnished its inpatients in a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS).   Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service or by the SNF under arrangements with the supplier.  If billed by the SNF, Medicare pays according to the Medicare Physician Fee Schedule.  SNFs submit  claims to the AB MAC (A) with type of bill 22X or 23X.  20.2.2 - Services Not Furnished in Hospitals  (Rev. 1, 10- 01-03)