To be eligible as a provider of independent x-ray services or portable x-ray services, a vendor must be certified by CMS for participation in the Medicare program.
To be eligible as a provider of the technical component (TC) of advanced diagnostic imaging (ADI) services, providers must be accredited through one of the accrediting organizations. The accreditation requirements apply only to providers of the TC of the imaging service and not the physician’s interpretation (professional component) of the imaging service. The accreditation requirements apply to all suppliers of the TC who submit claims to MHCP, except for the following organizations’ settings licensed by Minnesota Statutes:
Providers must be accredited for the modality, Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) imaging service for which they are billing or their claim will deny. ADI services include the following:
The accrediting organizations are:
The billing entity or organization must do the following:
Allow 30 days for MHCP to process the accreditation before submitting TC imaging service claims provided to fee-for-service recipients. Resubmit any claims denied prior to MHCP receiving the required information following timely billing requirements.
Contact the MCO directly for accreditation requirements and coverage policy.
Each of the accredited organizations will notify providers when it is time to renew accreditation. Providers must submit a new copy of their recertification with a new Advanced Diagnostic Imaging Accreditation Requirements – Assurance Statement (DHS-3872) (PDF) to MHCP Provider Enrollment.
To be eligible for MHCP payment for radiology or diagnostic services, the service must:
The professional component of a radiology procedure includes the professional services of the physician and the following:
The professional component is applicable in an encounter when the physician submits a charge for professional services only. It does not include the cost of personnel, materials, space, equipment, or other facilities.
The technical component of a radiology procedure code includes the personnel and materials, including:
Oral or rectal contrast administration alone does not qualify as a study "with contrast.”
Prior authorization is required for some covered imaging services. Refer to the Prior Authorization indicator column (PA IND) on the MHCP fee schedule for imaging procedures that require authorization. Submit authorization requests to the medical review agent, KEPRO.
MHCP covers medically necessary mammography services. All facilities (hospital, outpatient department, clinic, radiology practice, mobile unit, physician's office, or other facility) providing diagnostic and screening mammography services are required to have FDA certification under the Mammography Quality Standards Act (MQSA). No facility may conduct an examination or procedure involving mammography unless the facility has obtained an MQSA certificate.
MHCP no longer requires authorization for fee-for-service (FFS) radiology imaging services for the:
MHCP continues to require authorization for the technical component or global claim when a FFS Medicaid recipient accesses services in a setting other than those defined above.
Imaging services that require PAs will need to use the standard PA procedure of going through the KEPRO portal.
MHCP follows CMS General Coverage and Payment Policies (PDF) for IDTF providers.
CPT or HCPCS procedure codes performed by an IDTF that are solely therapeutic are not covered.
Do not bill a date span for services defined as multiple treatments or units of service.
Refer to the following when billing for IDTF services:
Refer to the following when billing for CT and MRI together:
Effective for dates of service on or after Jan. 01, 2016, MHCP follows Medicare’s requirement that providers must report modifier CT on all computed tomography scans performed on scanning equipment that does not meet the National Electrical Manufacturers Association (NEMA) standards. Refer to MLN Matters MM9250 for additional information.
For dates of service between Jan. 1 and Dec. 31, 2016, a payment reduction of 5 percent will apply to the technical component allowable. For dates of service on or after Jan. 1, 2017, a payment reduction of 15 percent will apply to the technical component allowable.
Effective for dates of service on or after Jan. 1, 2017, x-rays taken by film must include modifier FX. MHCP follows Medicare’s payment incentive to transition from film x-rays to digital radiography. Refer to MLM Matters MM9727 for additional information.
X-rays taken by film will have the technical component allowable reduced by 20 percent.
Refer to the following when billing for the professional component:
The technical component includes the charges for the following:
The technical component of all inpatient services is included in the inpatient DRG and billed electronically on the 837I.
For a provider transporting their own equipment to another site, the provider who owns the equipment may bill the technical components. To identify a charge for the technical component, enter the procedure code with a TC modifier.
Use modifier TC only when appropriate. If a CPT code is defined as the technical component only (of a service) do not use the TC modifier.
Injection of contrast material is part of the "with contrast" for CT, CTA, MRI and MRA procedures.
Total components include the technical and professional component. Use the appropriate procedure code without a modifier.
These types of procedures include professional, technical, and injection components. The Nuclear Regulatory Commission (NRC), under strict procedures and guidelines, regulates use of radiopharmaceuticals. People administering radiopharmaceuticals should have either a license from the NRC or be credentialed by an institution having a board license from the NRC.
Injection Component: Bill radiology procedures using the appropriate CPT code that indicates "with contrast," if available. Bill contrast media provided in a hospital with the appropriate CPT or HCPCS code on the 837I.
Contrast Material: Bill separately using most appropriate HCPCS code.
Contrast Media provided in an Inpatient Hospital: Bill the appropriate CPT or HCPCS code on the 837I.
Effective on or after Jan. 1, 2016, until Dec. 31, 2017, outpatient hospitals with type of bill 13X must report modifier CP for any planning services provided within 30 days before or after any cranial single session SRS treatment delivery services. Refer to CMS MLM Matters MM9486 for additional guidance.
Contrast Material: The phrase "with contrast" represents contrast material administered intravascularly, or intra-articularly injections for imagine enhancement.
Professional Component: A physician’s exam (when indicated), performance or supervision, interpretation, or written report of a radiology procedure.
Radiology: Radioactive substance's radiant energy and with the diagnostic and treatment of diseases by means of both ionizing and non-ionizing radiation.
Minnesota Statutes 256B.0625 Subd. 25a
Minnesota Statutes 144.1225 (Advanced Diagnostic Imaging Services)
Minnesota Rules 9505.0305 (Laboratory & X-ray Services)
Minnesota Rules 9505.0445 (Payment Rates)
42 CFR 410.33 (Independent Diagnostic Testing Facility)
42 CFR 410.34 (Mammography Service)
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