Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix L

A. Radiological Services

Codes for radiological services have three formats: professional component, technical component, and

complete procedure. Not all procedures have all three components. In general, these components should

be used as follows:

i. Professional Component: (26 modifier)

13. Radiology services should be billed as professional component when:

(a) The physician provides only the professional service for the procedure; or

(b) The service is provided in a hospital; or

(c) The technical portion of the service is performed by someone other than the

physician’s salaried employee.

ii. Technical Component: (TC modifier)

1. Radiology services should be billed as technical component when the physician is

providing the technical portion of the service only. This component has very limited

application under current Medicaid policy.

iii. Radiology Component (FX modifier)

iv. Complete Procedure

1. To bill for complete radiological procedures, which include charges for processing and

developing the x-ray (technical component), and evaluating the x-ray (professional

component), submit the codes as defined in the CPT without a modifier.

2. The physician may bill for complete procedure when one of the conditions outlined in

Part II Physician’s Manual, Section 601.5 of is met.

3. When billing for multiple identical radiology services performed on the same date of

service, charges must be placed on only one line of the claim form with the number of X-rays taken being placed in the “unit” space. To bill for identical bilateral procedures

where there is not an all-inclusive code bill the procedure code with a 50 modifier’ on

one line indicating one unit of service. Use of the 50 modifier will ensure correct

payment for both procedures using the one code. However, if there is an all-inclusive

procedure code for a bilateral procedure, the all-inclusive charge for the procedure will be

reimbursed at the lower of 100% of the allowed amount or the submitted charge.

v. Computerized Tomography - (CAT SCANS)

1. The Division reimburses for medically necessary CAT scans.

vi. Low Osmolar Contrast Media

1. Payment will be made for medically necessary low osmolar (non-trast material (LOCM)

used in conjunction with intrathecal, intra-arterial, and intravenous radiological

procedures when provided for non-hospital patients. The physician’s medical records

must support the medical necessity of low osmolar contrast material.

2. The following procedure codes must be used when billing for Low Osmolar Contrast

Media:

(a) Q9960 High Osmolar Contrast Material, 200-249 mg/ml Iodine Concentrate, per ml

(replacement for A4645).

(b) Q9961 High Osmolar Contrast Material, 250-299 mg/ml, Iodine Contrast, per ml

(replacement for A4645).

(c) Q9962 High Osmolar Contrast Material, 300-349 mg/ml, Iodine Concentration, per

ml (replacement for A4646).

(d) Q9963 High Osmolar Contrast Material, 350-399 mg/ml, Iodine Contrast Material

Concentration, per ml (replacement for A4646).

(e) Q9965 Low Osmolar Contrast Material, 100-199 MG/ML Iodine Concentration, per

ML (replaces Q9946)

vii. Magnetic Resonance Imaging (MRI)

1. Medically necessary MRI is covered by the Division when CT scans or SPECT

procedures are not definitive or appropriate. Only one MRI per day will be paid without

submission of documentation for medical necessity. Reimbursement for follow-up visits

by the radiologist is included in the reimbursement for the MRI. Please note that only

enrolled Medicaid providers may be reimbursed for MRI procedures.

2. CT scans or MRIs that do not require contrast, or are of a lower acuity, may be done

under the general supervision of the physician. CT scans and MRIs that require contrast,

or are at an increased level of acuity, must be performed under the direct supervision of

the physician.

viii. Portable X-Ray and CT scan

1. Effective July 1, 2017, the Department of Community Health provides payment of

medically necessary portable diagnostic x-ray and CT scan services to Medicaid eligible

members who are unable to travel to radiological facilities.

2. Specific diagnostic radiology services for an eligible member may be provided in a Home

Community Based Services, Skilled Nursing Facility Services, in Home Health and

Hospice Services to include the member’s home by an enrolled portable x-ray provider.

The X-ray and CT scan services are only considered for payment when they are

medically necessary and ordered by the member’s physician. Portable x-ray services are

allowable only in-Home Community Based Services, Skilled Nursing Facility Services,

in Home Health and Hospice Services (POS 31,32 or 33) or in a home setting (POS 12)

as medically necessary and appropriate, and under the supervision of a physician.

3. GA Medicaid does not reimburse for technical components for these services as a

separate part of the service. Providers billing for these services must bill a full component

only. GA Medicaid will not reimburse for set-up fee of the equipment (Level II HCPCS

code Q0092).

4. Transportation of portable x-ray equipment is reimbursable only when the equipment

used is transported to the location where x-ray services are provided. GA Medicaid will

not reimburse for the transportation of the portable x-ray equipment when the x-ray

equipment is stored at a facility for use as needed.

5. GA Medicaid will only pay for single transportation payments per trip to a facility or

location for a single date of service. Therefore, providers should make every effort to

schedule all members at a single location during a single trip to that location. If more than

one member at the same location is x-rayed, the portable X-ray transportation fee is

allocated among the members who receive portable X-ray services in a single trip.

6. GA Medicaid reimburses procedure code R0075 (Transportation of portable X-ray

equipment), per trip to facility or location for portable X-ray providers, more than one

member seen. The Division also reimburse procedure code R0070 (Transportation of

portable X-ray equipment), per trip to facility or location, one member seen.

7. When submitting a claim for procedure code R0075, the provider is required to use a

modifier to indicate the total number of Medicaid members served at the location. The

provider is required to submit a separate claim for each Medicaid member. A claim with

procedure code R0075 will be denied if it is submitted without an appropriate modifier.

Each claim for a single location and data of service must indicate the same X-ray

transportation procedure code and modifier for all members seen during that visit.

(a) R0070 Portable x-ray equipment and personnel to the member’s home or nursing

home, per trip to a facility or other location.

(b) R0075 Transportation of portable x-ray equipment and personnel to home or nursing

home, per trip to facility or location, more than one member seen, per trip to facility

or location. The following modifiers are to be billed with R0075:

8. Modifiers: (no modifier if one patient served)

(a) UN - Two patients served

(b) UP - Three patients served

(c) UQ - Four patients served

(d) UR - Five Patients served

(e) US - Six or more patients served

The written order must be written and ordered by the member’s primary care physician before

any portable or mobile x-rays and /or CT scan services are provided. The claim for

reimbursement must indicate the name of the physician who ordered the service before payment

may be made.

Portable X-ray services may be provided to a member in his or her place of residence. The

member place of residence is defined by the Division of Medicaid as the member’s own dwelling,

a residential care facility or nursing facility. Portable X-ray services are not covered in hospital

settings.

NOTE:

GA Medicaid will only pay for a single transportation payment per trip to a facility or location

for a single date of service. Therefore, providers should make every effort to schedule all

members at a single location during a single trip to that location.

All providers, including their staff, contracted staff and volunteers must comply with the Health

Insurance Portability and Accountability Act (HIPAA) privacy requirements.

The portable x-ray provider is responsible for determining that a member is Medicaid eligible on

the date of service.

ix. Portable x-ray providers must keep the following records for each member for a period of at least

7 years:

1. A copy of the written, signed and dated order by the member’s physician,

2. The date of the x-ray examination,

3. The name of the physician who performed the professional interpretation of the

procedure, and

4. The date the radiograph was sent to the physician.

x. Portable x-ray providers will not be reimbursed for the following services:

5. Procedures involving fluoroscopy,

6. Procedures involving the use of contrast media,

7. Procedures requiring the administration of a substance to the member, the injection of a

substance, or the spinal manipulation of the member,

8. Procedures requiring special technical competency and/or special equipment or materials,

9. Routine screening procedures such as annual physicals,

10. Procedures which are not of a diagnostic nature, e.g., therapeutic x-ray treatments, and

11. Annual x-rays.

xi. Fee Schedule:

1. Information regarding the Fee Schedule to be used for Portable X-rays and CT scan can

be obtained on www.gammis.com following the links under “Provider Manual”,

“Provider Information”, and “Fee Schedules.”

xii. Mammography

1. All mammograms must be performed at a state certified center, and the results must be

interpreted by a physician certified by the American Board of Radiology, or the

American Osteopathic Board of Radiology, or certified as qualified to interpret the results

of mammograms as determined by the Secretary of Health and Human Services. Contact

the office below with questions on obtaining certification.

Office of Regulatory Services Health Care Services

Georgia Department of Community Health

2 Martin Luther King Jr Dr. SE, East Tower 19th Floor,

Atlanta, GA 30334

(404) 657-5407

The Division must have an update and valid copy of your certification. Please fax new certification to Gainwell

Technologies at 1-866-483-1044 or 1-866-483-1045 or forward to:

Prior Authorization & Pre-Certification AHS

PO Box 105329 Atlanta, Georgia 30348

800-766-4456 (Toll free)

When billing for mammography on the CMS 1500 claim form, enter the radiology center’s 6digit certification

number on field 24a, with the preceding EW qualifier. Please refer to Policies and Procedures for Medicaid

PeachCare for Kids Part 1 Manual for billing instructions.