Medicare Advantage Medical Policy Bulletin
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

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). 

Procedure Codes

Coding Guidelines

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.

References

Centers for Medicare and Medicaid Services

Deficit Reduction Act of 2005

MedLearn Matters # SE0587, SE0665

CMS Manual Pub. 100-20, Transmittal 694, CR 6965

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Family 01 - Ultrasound (Chest/Abdomen/Pelvis-Non-Obstetrical)

76604767007670576770
76775767767683176856
7685776870  

Family 02 - CT and CTA (Chest/Thorax/Abdomen/Pelvis)

71250712607127071275
72191721927219372194
74150741607417074175
756350067T  

Family 03 - CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck)

70450704607047070480
70481704827048670487
70488704907049170492
7049670498  

Family 04 - MRI and MRA (Chest/Abdomen/Pelvis)

71550715517155271555
72195721967219772198
74181741827418374185
75557755597556175563
7705877059  

Family 05 - MRI and MRA (Head/Brain/Neck)

70336705407054270543
70544705457054670547
70548705497055170552
7055370554  

Family 06 - MRI and MRA (Spine)

72141721427214672147
72148721497215672157
72158   

Family 07 - CT (Spine)

72125721267212772128
72129721307213172132
72133   

Family 08 - MRI and MRA (Lower Extremities)

73718737197372073721
737227372373725 

Family 09 - CT and CTA (Lower Extremities)

73700737017370273706

Family 10 - MRI and MRA (Upper Extremities and Joints)

73218732197322073221
7322273223  

Family 11 - CT and CTA (Upper Extremities)

73200732017320273206

Diagnosis Codes

Glossary




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.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.