CARECORE NATIONAL OUTPATIENT IMAGING SELF-REFERRAL PAYMENT POLICIES PUBLISHED APRIL 2013

Transcription

1 CARECORE NATIONAL OUTPATIENT IMAGING SELF-REFERRAL PAYMENT POLICIES PUBLISHED APRIL 2013 The outpatient imaging self-referral payment policies are designed to promote appropriate use of diagnostic imaging by primary care physicians, specialty physicians and other health care professionals in office settings. The CareCore National payment policies below designate which imaging procedures shall be payable by the health plan (subject to member benefits) in primary care physicians, specialty physicians and other health care professionals offices by provider practice specialty. In addition, these payment policies describe the minimum accreditation and certification requirements for ultrasound, echocardiography and nuclear medicine. This payment policy assumes board certification (by an ABMS recognized board) in the provider specialties listed below. All specialty payment policies apply to the related pediatric specialties as well. Primary Care Physicians: to Chest imaging Internal Medicine, Family Practice Cardiologists (includes cardiovascular specialist, interventional cardiologist, and cardiac electrophysiologist) to Chest imaging pericardiocentesis endomyocardial biopsy Cardiologists, Nuclear 78451*, 78452*, 78453*, 78454* 78466*, 78468*, 78469* 78472*, 78473*, 78481*, 78483*, 78494* Myocardial perfusion imaging Myocardial infarction scans Cardiac blood pool imaging 1.) Certification by the American Board of Radiology (ABR), the American Board of Nuclear Medicine (ABNM) or the Certification Board for Nuclear Cardiology (CBNC) 2.) Laboratories accredited by the Intersocietal Commission for the Accreditation of Nuclear Laboratories (IAC Nuclear/PET)*** or the American College of Radiology (ACR) NY021680_PRO_LTR_ENG Internal Approved WellCare 2013 NY_03_

2 Pediatric Cardiologists 76825** to 76828** Echocardiography, fetal 71555* MRA Chest 75557* to 75563* Cardiac MRI to Chest imaging pericardiocentesis endomyocardial biopsy Chiropractors 72010, 72040, 72069, 72070, 72080, Colon & Rectal Surgeons Spine imaging Ultrasound, transrectal biopsy Endocrinologists Thyroid ultrasound biopsy 1.)Certification in pediatric cardiology by the American Board of Pediatrics 2.)Laboratories accredited by the Intersocietal Accreditation Commission for Echocardiography Laboratories (ICAEL) Certification by the American Board of Colon & Rectal Surgery (ABCRS) AACE/ECNU (Endocrine Certification for Neck Ultrasound) Accreditation Gastroenterologists Endoscopic ultrasound General Surgeons biopsy Breast ultrasound For breast ultrasound and ultrasound-guided breast biopsy: Hand Surgeons to Upper extremity imaging Physicians must be certified in breast ultrasound by the American Society of Breast Surgeons (ASBS) -and- Facilities must have accreditation from the ASBS for breast ultrasound and ultrasound-guided breast biopsy or be accredited by the American College of Radiology in breast ultrasound and ultrasound-guided breast biopsy Head and Neck Surgeons (ENT, otolaryngologist) Hematologist/Oncologists Medical Oncologists Oncologists biopsy to Chest imaging

3 Maternal and Fetal Medicine Hysterosalpingography Computer aided detection, 77057, G **, 76816**, 76817**, 76820**, 76821** to **, 76802**, 76805**, 76810**, 76811**, 76812**, 76813**, 76814**, 76818**, 76819**, 76820**, 76821**, 76825**, 76826**, 76827**, 76828** Nephrologists * Screening Mammography Ultrasound: obstetrical, pelvic, guidance Ultrasonic guidance aspiration of ova Ultrasound: obstetrical, pelvic, guidance Ultrasound study, follow-up fetal transfusion or cordocentesis chorionic villus sampling amniocentesis Angiography arteriovenous shunt, radiological supervision and interpretation Venous angioplasty, radiological supervision and interpretation MR guidance for needle placement CT scan for needle biopsy Fluoroscopic guidance biopsy Must be fully compliant with MQSA requirements to perform AIUM/ACR Accreditation Nuclear Medicine All nuclear medicine studies are included in this section, please consult your Provider Manual to determine which nuclear studies require pre-certification. Or call CareCore National for assistance at Physicians must be certified by the American Board of Radiology (ABR) or the American Board of Nuclear Medicine (ABNM).

4 OB/GYN Computer aided detection, 77057, G0202 Screening Mammography Hysterosalpingography 76815**, 76816**, 76817** to Ultrasound: obstetrical, pelvic Ultrasonic guidance aspiration of ova **, 76802**, 76805**, 76810**, 76811**, 76812**, 76813**, 76814**, 76818**, 76819**, 76820**, 76821**, 76825**, 76826**, 76827**, 76828** Ultrasound study, follow-up Ultrasound: obstetrical, pelvic Must be fully compliant with MQSA requirements to perform AIUM/ACR accreditation fetal transfusion or cordocentesis chorionic villus sampling amniocentesis Oral Surgeons 70100, 70110, 70140, , 70310, , Orthopedists (including Pediatric Orthopedists) to to to 72120,72170, 72190, to to 73140, to , 77003* Mandible and facial bone imaging Teeth imaging TMJ imaging Cephalogram, orthodontic orthopantogram Radiologic examination, ribs Radiologic examination, sternum Spine and pelvis imaging Imaging to upper and lower extremities Fluoroscopic guidance biopsy Radiologic examination, any joint Bone length studies Joint survey Ultrasound, extremity Ultrasound, extremity, limited Ultrasound, infant hips Ultrasound, infant hips, limited Pain Specialists (physiatrists, 72275* Epidurography anesthesiologists, neurologists, and neurosurgeons) 77002, 77003* Fluoroscopic guidance Pediatricians to Chest imaging AIUM accreditation in musculoskeletal ultrasound

5 Podiatrists 73620, 73630, 73650, Lower extremity imaging Pulmonologists to Chest Imaging Radiation Oncologists CT guidance for needle placement CT guidance for placement of radiation therapy fields Prostate volume study for brachytherapy treatment planning placement of radiation therapy fields interstitial radioelement application Reproductive Endocrinologists Computer aided detection, 77057, G0202 Screening Mammography Ultrasound, obstetrical, pelvic 76815**, 76816**, 76817** to Rheumatologists to 72120,72170, to to 73140, to , Ultrasound study, follow-up Hysterosalpingography Spine and pelvis imaging Imaging - Upper and lower extremities Must be fully compliant with MQSA requirements to perform 77073, Sports Medicine to , to , to to to biopsy Bone length studies, joint survey Ultrasound, extremity Ultrasound, extremity, limited Ultrasound, infant hips Ultrasound, infant hips, limited Radiologic examination, ribs Radiologic examination, sternum Spine and pelvis imaging Imaging to upper and lower extremities AIUM accreditation in musculoskeletal ultrasound Board certification in sports medicine and combined fellowship, residency and training in sports medicine of at least four years

6 Urologists Ultrasound, retroperitoneal, limited 76870, Ultrasound, scrotum, transrectal Prostate volume study for brachytherapy treatment planning Ultrasound guidance for biopsy Ultrasound guidance for interstitial radioelement placement Ultrasound, pelvic, limited or follow up Vascular Neurology Vascular Surgeons Aortography, thoracic, without serialography Angiography, external carotid, unilateral, selective Angiography, external carotid, bilateral, selective Angiography, carotid, cerebral, unilateral Angiography, carotid, cerebral, bilateral Angiography, carotid, cervical, unilateral Angiography, carotid, cervical, bilateral Angiography, vertebral, cervical and/or intracranial Transcatheter therapy, embolization Transcatheter therapy, infusion Angiography through existing catheter Cineradiography/ Videoradiography Fluoroscopic guidance for central venous access device Ultrasound guidance for vascular access Certification by the American Board of Medical Specialties (ABMS) in Vascular Neurology