Policy Statement
In the inpatient hospital setting, CXR is eligible for reimbursement when supported by a treating physician’s signed written order and documented interpretation and report in the patient’s medical record. When a physician issues a signed written order for one (1) CXR with multiple views, only one charge is eligible for reimbursement. Unbundling CXR into component views is not separately reimbursable. CXR views include, but are not limited to, the following:
- Single view
- 2 views
- 3 views
- 4 or more views
For example, a physician issues a signed written order of one (1) CXR, 2 views. Based on the physician’s signed written order, only one (1) charge is eligible for reimbursement. Unbundling the service into 2 single views is not separately reimbursable.
Multiple CXRs performed at separate sessions on the same day must be clearly documented in the patient’s medical records to be considered for reimbursement. Documentation must include a physician signed written order and CXR interpretation and report. Repeating CXR due to provider technical error is not reimbursable.
Inpatient hospitals providing both the technical and professional components of CXR are reimbursed globally. Neither the professional nor technical component is separately reimbursable.
Only one (1) physician/radiologist is eligible for reimbursement for CXR interpretation (professional component).
Reimbursement may be divided into a technical component or TC (performing the CXR) and a professional component or PC (interpretation and report of the CXR), if performed by an independent billing physician/radiologist (not affiliated with the hospital). Condition of reimbursement includes, but is not limited to, the following:
- When the professional component is billed, it is eligible for reimbursement, if modifier 26 is appended to the radiology code to reflect the work associated with the professional component only.
- The facility is reimbursed for the technical component (TC) only.
- Global CXR service (PC and TC components) to an independent physician/radiologist is not reimbursable.
- The patient’s medical record must support the interpretation and report as an independent reimbursable service, including, but not limited to, the following:
- The report is identifiable as a separate report
- Name of patient
- Date of patient’s birth and age
- Patient’s identification number
- Name of the ordering physician’s name
- Date the technical portion of CXR was performed
- Interpretation and report
- Legible signature by interpreting physician/radiologist and date of interpretation noted
Interpretation of CXR, when performed solely for the purpose of quality control as a service to the hospital rather than a service to the patient, is not reimbursable.
Radiologic Guidance for Needle Placement Procedures
According to the Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual, diagnostic tests including radiologic guidance must be ordered and signed by the treating physician and the test must be personally performed or supervised by an attending physician.
Radiologic guidance in the inpatient hospital setting is eligible for reimbursement when the following are all met:
- When supported by a referring physician’s written order and documented procedure report in the patient’s medical record.
- When the attending or supervising physician is present.
- When the radiologic guidance report is signed by the supervising/attending physician.
Radiologic guidance is not eligible for reimbursement:
- When performed by a diagnostic radiology resident or an American College of Radiology fellow without the presence of the attending physician.
- When billed more than one (1) per day.
Radiological supervision and interpretation (S&I) for fluoroscopic guidance, ultrasonic guidance, CT guidance and MRI guidance for needle placement procedures (e.g., biopsy, aspiration, injection, localization device) are considered part of the needle placement procedure. Unbundling of the radiologic guidance (including S&I service component) from the needle placement procedure is not separately reimbursable.
Drugs and Supplies
Drugs and medical/surgical supplies used during the radiologic guidance procedure are considered integral components of a diagnostic radiologic procedure and are not separately reimbursable. Unbundling drugs and medical/surgical supplies from the radiologic guidance procedure is not separately reimbursable.
Diagnostic radiopharmaceuticals and certain imaging agent(s) are an integral component to the diagnostic procedure. Unbundling imaging agent(s) from the diagnostic procedure is not separately reimbursable. Note: Therapeutic radiopharmaceuticals are eligible for reimbursement.
Our health plan’s reimbursement policy is aligned with the CMS guidelines and methodologies as well as coding guidelines. It was developed in part using American College of Radiology Diagnostic Guidance - General Practice Guidelines.
References
- American College of Radiology, “Diagnostic Guidance - General Practice Guidelines.”
- Centers for Medicare & Medicaid Services (CMS), “Medicare Claims Processing Manual”, Chapter 13 – Radiology Services and Other Diagnostic Procedures.
- Centers for Medicare & Medicaid Services (CMS), “Medicare Benefit Policy Manual", Chapter 1 – Inpatient Hospital Services Covered Under Part A.
- Centers for Medicare & Medicaid Services (CMS), “Medicare Benefit Policy Manual”, Chapter 15 – Covered Medical and Other Health Services, Section 30.1 – Provider-Based Physician Services.
- Centers for Medicare & Medicaid Services (CMS), Local Coverage Determination (LCD): Chest X-Ray Policy (L37547).
- Cornell Law School Legal Information Institute, “42 CFR § 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.”
- American Medical Association. Current Procedural Terminology (CPT®).
Cross References
- Adm 129 – Correct Coding Guidelines
- Mod 106 – Modifier 26; Professional Component Modifier TC; Technical Component
