Policy
The Centers for Medicare & Medicaid Services (CMS) established a reimbursement methodology for certain multiple diagnostic imaging services performed on the same patient, on the same day, during the same imaging session, by the same physician/QHP or physician/group practice. The reimbursement methodology is separated into three groups based on the three diagnostic imaging families which are
- Diagnostic Imaging Services
- Diagnostic Cardiovascular Imaging Services
- Diagnostic Ophthalmology Imaging Services
The multiple reduction reimbursement methodology applies independently to the specific diagnostic imaging families when multiple imaging services within the same family are performed for the same patient during the same imaging session on the same date of service by the same physician/QHP or physician/Group practice.
The technical component of radiology services furnished to hospital patients is included in the hospital claim and should not be billed on a professional claim.
Modifier 59
When multiple diagnostic imaging services within the same diagnostic imaging family are performed on the same day for the same patient, but at different imaging sessions, modifier 59 must be reported for the subsequent session(s) to allow separate reimbursement. Modifier 59 should not be appended when all imaging services are rendered during the same imaging session.
Multiple Diagnostic Imaging Reduction (MDIR) Methodology
Diagnostic services subject to the MDIR methodology can be identified in the CMS National Physician Fee Schedule Relative Value Unit (NPFSRVU) File under the column MULT PROC with indicator “4”. This MDIR applies to both professional and technical services when these diagnostic imaging services are performed for the same patient during the same imaging session on the same date of service by the same physician/QHP or physician/Group practice. This includes all outpatient institutional radiology claims and ambulatory surgical center (ASC) claims billed on the UB-04 Claim Form as well as physician, QHP, or allied provider claims billed on the CMS-1500 Claim Form.
Professional Component Reduction
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Payment will be made at 100% for the professional component of the imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “4” will be made at 95% of the allowance for the professional component.
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Technical Component Reduction
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Payment will be made at 100% for the imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “4” will be made at 50% of the allowance for the technical component.
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Note: Services billed on the UB-04 Claim Form are always considered Technical Component only services and apply to the technical component reduction. Institutional services require the appropriate revenue code for the service and a line-item date of service.
Diagnostic Cardiovascular Imaging Reduction (DCIR) Methodology
Diagnostic cardiovascular services subject to the DCIR methodology can be identified in the CMS National Physician Fee Schedule Relative Value Unit (NPFSRVU) File under the column MULT PROC with indicator “6”. The DCIR applies to the technical portion of the global services when these diagnostic cardiovascular imaging services are performed for the same patient during the same imaging session on the same date of service by the same physician/QHP or physician/Group practice for claims billed on the CMS-1500 Claim Form. The DCIR does not apply to the professional component of these services.
Technical Component Reduction
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Payment will be made at 100% for the cardiovascular imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “6” will be made at 75% of the allowance for the technical component.
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Diagnostic Ophthalmology Imaging Reduction (DOIR) Methodology
Diagnostic ophthalmology services subject to the DOIR methodology can be identified in the CMS National Physician Fee Schedule Relative Value Unit (NPFSRVU) File under the column MULT PROC with indicator “7”. The DOIR applies to the technical portion of the global services when these diagnostic ophthalmology imaging services are performed for the same patient during the same imaging session on the same date of service by the same physician/QHP or physician/Group practice for claims billed on the CMS-1500 Claim Form. The DOIR does not apply to the professional component of these services.
Technical Component Reduction
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Payment will be made at 100% for the ophthalmology imaging procedure with the highest allowance. Payment for additional imaging services with a CMS NPFSRVU File indicator of “7” will be made at 80% of the allowance for the technical component.
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Note: BCBSND updates codes quarterly when made available by CMS and the American Medical Association (AMA). The official update of the Healthcare Common Procedure Coding System (HCPCS) for public use is located at https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update The official update of the AMA is located at https://www.ama-assn.org/.
Limitation and Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
Date
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Updates
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3/30/20
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Moved information about modifier 59 into a separate section for better visibility
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5/28/20
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Made edits to show when this policy applies to claims billed on the CMS-1500 and/or UB-04 claim forms.
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4/25/21
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Added a note that codes are updated quarterly.
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4/28/22
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Updated formatting.
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4/24/23
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Performed annual review of policy.
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