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| Section: | CMS National Guidelines |
| Number: | N-69 |
| Topic: | Multiple Procedure Payment Reduction for the Technical Component of Certain Diagnostic Imaging Procedures (See Reference Section) |
| Effective Date: | July 1, 2010 |
| Issued Date: | July 5, 2010 |
| General Policy Guidelines | Procedure Codes | Coding Guidelines | References | Attachments | Procedure Code Attachments | Diagnosis Codes | Glossary |
In 2006, the Centers for Medicare and Medicaid Services (CMS) implemented a new reimbursement methodology for multiple diagnostic imaging procedures performed for the same patient on the same day during the same imaging session. Medicare Advantage plans will also apply this same payment methodology to the technical component for the same imaging procedures.
Indications and Limitations of Coverage
When certain diagnostic imaging services or procedures are performed for the same patient during the same imaging session on the same date of service, payment will be made at 100 percent for the imaging procedure with the highest allowance. For additional imaging services performed on contiguous anatomic areas during the same imaging session, payment for the technical component portion only will be reduced to 50% of the allowance for the technical component.
The Procedure Code Attachment located at the end of this policy provides a reference list of the 11 imaging family groups of codes that are subject to this technical component payment reduction. Each grouping is based on the imaging modality used and contiguous body areas.
When multiple imaging services within the same 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).
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When multiple imaging services are performed on the same day for the same patient, but at different imaging sessions, modifier -59 must be reported for the second session.
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Centers for Medicare and Medicaid Services
Deficit Reduction Act of 2005
MedLearn Matters # SE0587, SE0665
CMS Manual Pub. 100-20, Transmittal 694, CR 6965
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Family 01 - Ultrasound (Chest/Abdomen/Pelvis-Non-Obstetrical)
| 76604 | 76700 | 76705 | 76770 |
| 76775 | 76776 | 76831 | 76856 |
| 76857 | 76870 |
Family 02 - CT and CTA (Chest/Thorax/Abdomen/Pelvis)
| 71250 | 71260 | 71270 | 71275 |
| 72191 | 72192 | 72193 | 72194 |
| 74150 | 74160 | 74170 | 74175 |
| 75635 | 0067T |
Family 03 - CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck)
| 70450 | 70460 | 70470 | 70480 |
| 70481 | 70482 | 70486 | 70487 |
| 70488 | 70490 | 70491 | 70492 |
| 70496 | 70498 |
Family 04 - MRI and MRA (Chest/Abdomen/Pelvis)
| 71550 | 71551 | 71552 | 71555 |
| 72195 | 72196 | 72197 | 72198 |
| 74181 | 74182 | 74183 | 74185 |
| 75557 | 75559 | 75561 | 75563 |
| 77058 | 77059 |
Family 05 - MRI and MRA (Head/Brain/Neck)
| 70336 | 70540 | 70542 | 70543 |
| 70544 | 70545 | 70546 | 70547 |
| 70548 | 70549 | 70551 | 70552 |
| 70553 | 70554 |
Family 06 - MRI and MRA (Spine)
| 72141 | 72142 | 72146 | 72147 |
| 72148 | 72149 | 72156 | 72157 |
| 72158 |
Family 07 - CT (Spine)
| 72125 | 72126 | 72127 | 72128 |
| 72129 | 72130 | 72131 | 72132 |
| 72133 |
Family 08 - MRI and MRA (Lower Extremities)
| 73718 | 73719 | 73720 | 73721 |
| 73722 | 73723 | 73725 |
Family 09 - CT and CTA (Lower Extremities)
| 73700 | 73701 | 73702 | 73706 |
Family 10 - MRI and MRA (Upper Extremities and Joints)
| 73218 | 73219 | 73220 | 73221 |
| 73222 | 73223 |
Family 11 - CT and CTA (Upper Extremities)
| 73200 | 73201 | 73202 | 73206 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
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