Multiple Radiology Payment Reduction (Healthy Blue + Medicare (HMO D-SNP))

Reimbursement Policy  

Subject: Multiple Radiology Payment Reduction  

Policy Number: G-12002 Policy Section: Radiology

Last Approval Date: 08/15/2022 Effective Date: 08/15/2022

Visit our provider website for the most current version of our reimbursement policies. If you are using a printed version of this policy, please verify the information by going to Healthy Blue + Medicare. 

Disclaimer

These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by Blue Cross and Blue Shield of North Carolina (Blue Cross NC) if the service is covered for Healthy Blue + Medicare℠ (HMO D-SNP). The determination that a service, procedure, item, etc. is covered under a member’s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence. You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be billed with CPT® codes, HCPCS codes, and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to participating providers and facilities; a noncontracting provider who accepts Medicare assignment will be reimbursed for services according to the original Medicare reimbursement rates.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, Blue Cross NC Medicare Advantage may:

• Reject or deny the claim.
• Recover and/or recoup claim payment.

Blue Cross NC Medicare Advantage reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal, or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, Blue Cross NC Medicare Advantage strives to minimize these variations.

Blue Cross NC Medicare Advantage reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to our provider website.

Policy

Blue Cross NC Medicare Advantage reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to our provider website.

Blue Cross NC Medicare Advantage allows professional and facility reimbursement for multiple diagnostic imaging procedures unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.
Multiple diagnostic imaging procedures will be subject to a multiple procedure payment reduction (MPPR) when services are performed by the same provider or provider group, on the same date of service, during the same patient encounter. CT scan services are not subject to a multiple procedure payment reduction.

The global procedure, professional component, or technical component of diagnostic imaging procedures will reimburse at 100% of the contracted/negotiated rate for each professional component and technical component service with the highest payment. Reimbursement of subsequent services is based on:

• 95% of the professional component.
• 50% of the technical component.

A reduced allowance for the second and subsequent procedures will not apply when multiple imaging procedures are billed appended with Modifier 59 or X{EPSU} to indicate the procedure was done on the same day but not during the same session.

A single imaging procedure is subject to the multiple imaging reductions when submitted with multiple units.

Related Coding

• Standard correct coding applies

Policy History  

• 8/15/2022 Review approved: policy template updated; minor language changes to policy section
• 01/01/2021 Initial approval and effective

References and Research Materials

This policy has been developed through consideration of the following:

• CMS
• State contract
• Blue Cross NC Medicare Advantage contract(s)

Definitions 

• General Reimbursement Policy Definitions

Related Policies and Materials

• Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
• Modifier 26 and TC: Professional and Technical Component
• Modifier Usage

For more information, visit our Provider Page.

Healthy Blue + Medicare℠ (HMO D-SNP) is a Medicare Advantage plan offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Certain administrative services for Healthy Blue + Medicare are provided by Amerigroup Partnership Plan, LLC (Amerigroup) pursuant to an administrative services agreement. References to Blue Cross NC may mean Blue Cross NC or their designee, Amerigroup.

NCBCBS-CR-RP-018472-23-CPN17260 February 2023