HealthCare News

Multiple Advanced Radiology Services – Institutional and Professional

Issue: #397 NOV2017

Topic: Reimbursement

Blue Cross Blue Shield of North Dakota (BCBSND) follows the full/half/half discounting of the technical component (TC) of multiple advanced radiology procedures according to the published CMS list of procedures for CT scans, MRIs and ultrasounds. This includes all outpatient institutional radiology claims billed on the UB-04 as well as ambulatory surgical centers (ASCs) and physician/allied provider claims billed on the CMS-1500. The reduction applies to the TC-only services and the TC portion of global services. Services billed on the UB-04 are always considered to be TC-only services. Institutional services require the appropriate revenue code for the service and a line-item date of service.

Multiple services billed globally on the CMS-1500 (as identified by no modifier), are separated into technical and professional components. The reduction is taken on the technical portion of the service only and does not apply to professional component (Modifier 26) services.

The technical component of radiology services (CPT® codes 70000-79999) furnished to hospital patients is included in the hospital claim and should not be billed on a professional claim. If a technical component of a radiology procedure is billed with a hospital place of service on a professional claim, it will be returned to the provider.

Allowed payment will be 100 percent for the highest-priced procedure and 50 percent for each additional procedure when performed during the same session on the same day by the same physician or allied provider. Reimbursement is based on the lesser of charges or adjusted fee schedule amount. A single session is one encounter in which a patient could receive one or more consecutive radiological studies. Radiology procedures submitted with multiple units or modifier 50 will receive the multiple-image reduction. For example, if CPT® code 73202 is submitted with 2 units, the 50 percent reduction will apply to the second unit.

If the patient has a separate encounter on the same day for a medically necessary reason and receives a second advanced imaging service, it is considered a separate session and will not receive the multiple-imaging reduction. If a separate image is performed at a separate session on the same day as another advanced radiology procedure, modifier 59 should be appended to the TC of the separate procedure. Documentation must support that the second imaging service was provided in a separate session.

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