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1. INSURANCE COMPANIES

PAYOR: Monarch
Action Items:
a) Front Desk: Lookup the Monarch Auth # online. Make sure the authorized CPT/Exam is in RIS.
b) Technologists: For Monarch patients, do not change the exam to other CPT/Exam. We will not be reimbursed.
IF THE EXAM HAS TO BE CHANGED, Front desk must get new auth #, even if the patient has to come back for the other medically necessary procedure. Otherwise OCD will not be reimbursed

2. MRA

Payor: Medicare Medicaid
Question: Using 3D Reconstruction code 76375 in conjunction with MRA and CTA sequences.

76375 should not be billed in conjunction with MRA or CTA. Reconstruction is included in the reimbursement for these procedures.


3. CT

Payor: Medicare
Question: Physician order a CT of the Chest, Abdomen, and Pelvis with indications for each. Another team is consulted an orders a lumbar spine. The original data from the previous scans contain all the information that is needed to reconstruct a lumbar spine without irritating the patient again. How should we bill. 76375 doesn't seem appropriate if the radiologist dictates a lumbar spine.

76375 can be billed with a CT scan if performed. The purpose of the lumbar films is unclear. If the lumbar films are ordered and performed for diagnostic purposes, the service can be billed.


Question: Physician orders a CT scan of the abdomen and pelvis without contrast (kidney protocol). A few hours later, Physician orders a CT scan of the abdomen and pelvis to r/o mass. Can I use a modifier 59 with this and bill for both studies?

This service should be billed as a CT abdomen/pelvis w/o folllowed by w/ contrast. Experience has shown that regardless of how this service is billed, insurance plans will combine for payment. Billing w/ a '59 modifier will only delay or deny payment.


Question: How to code for a CT without contrast and then with contrast on the same day but approx. 4 hours apart. I know there is a combination code but the manager wants some documentation as to why we cannot bill both procedure separately. Is there some guideline that states why we would be billing fradulently for both codes?

The question is not about fraudulent billing. It is a question of practicality. When these services are billed separately on the same service date, they will be paid the combined rate after they go through a recoding process. Billing them separately would be considered fragmenting until you could prove otherwise. This would require manual appeals with documentation to support both services. The chance of getting additional money is slim and the cost of the appeal in addition to the slow down of the cash flow would be prohibitive.

4. 3D Imaging

Question: Which cpt codes are to be billed for MRA Aorta with runoff?

Because there is not a specific code for MRA of the aorta with run-off, separate codes should be submitted. MRA may allow discovery of abdominal aortic aneurysm or other vascular anomalies. Medicare covers this MRA code, but its use may be restricted. Submit code 74185 for the aorta. Submit code 73725 for the lower extremity MRA. Assign modifier 50 to code 73725 if both extremities are evaluated and documented. Insure separate paragraphs in the report identify each portion of the studies performed to insure supporting documentation for your coding.

Submit code 72198 for MRA of the pelvis in addition to codes 73725 x2. Current Medicare rules indicate that bilateral lower extremity MRA will be paid at 100% for each extremity.


Question: Orbital or temporal bone exams include axial and coronal imaging (direct scanning- not reformatting.) Does code 70480 cover both sets of images - we do not bill 76375 as no reformatting is done. Is this correct? Other ways to bill?

From a Medicare perspective only specific screening procedures can be billed to Medicare. For example - occult blood, mammography, prostate, pap smear. Other screening procedures will be denied by Medicare and if the facility had received an ABN the patient would be responsible for payment. Other payers will have their own rules based on the contractual agreement with your facility.


Payor: Medicare
Question: Must 3D reconstruction be specified on a referring physician order--or has it yet become accepted as a standard of care protocol that the radiologist can specify?

For studies performed in a free standing imaging center a separate order must be obtained. Reference CMS transmittal 1725 dated September 1, 2001.