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: 71010 to 71030 Chest imaging Internal Medicine, Family Practice Cardiologists (includes cardiovascular specialist, interventional cardiologist, and cardiac electrophysiologist) 71010 to 71030 76930 76932 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 03202013 WellCare 2013 NY_03_13 51471
Pediatric Cardiologists 76825** to 76828** Echocardiography, fetal 71555* MRA Chest 75557* to 75563* Cardiac MRI 71010 to 71030 Chest imaging 76930 pericardiocentesis 76932 endomyocardial biopsy Chiropractors 72010, 72040, 72069, 72070, 72080, 72100 Colon & Rectal Surgeons 76872 Spine imaging Ultrasound, transrectal biopsy Endocrinologists 76536 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 76975 Endoscopic ultrasound General Surgeons 76645 biopsy Breast ultrasound For breast ultrasound and ultrasound-guided breast biopsy: Hand Surgeons 76000 73100 to 73140 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 71010 to 71030 Chest imaging
Maternal and Fetal Medicine 74740 Hysterosalpingography 77052 Computer aided detection, 77057, G0202 76815**, 76816**, 76817**, 76820**, 76821** 76830 to 76857 76948 76801**, 76802**, 76805**, 76810**, 76811**, 76812**, 76813**, 76814**, 76818**, 76819**, 76820**, 76821**, 76825**, 76826**, 76827**, 76828** 76970 76941 76945 76946 Nephrologists 75791 75978 77021* 77002 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 78000 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 1-888-333-8641. Physicians must be certified by the American Board of Radiology (ABR) or the American Board of Nuclear Medicine (ABNM).
OB/GYN 77052 Computer aided detection, 77057, G0202 Screening Mammography 74740 Hysterosalpingography 76815**, 76816**, 76817** 76830 to 76857 Ultrasound: obstetrical, pelvic 76948 Ultrasonic guidance aspiration of ova 76970 76801**, 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 76941 76945 76946 fetal transfusion or cordocentesis chorionic villus sampling amniocentesis Oral Surgeons 70100, 70110, 70140, 70150 70300, 70310, 70320 70328, 70330 70350 70355 Orthopedists (including Pediatric Orthopedists) 71100 to 71111 71120 to 71130 72010 to 72120,72170, 72190, 72200 to 72220 73000 to 73140, 73500 to 73660 76000 77002, 77003* 77071 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 77073 77077 Bone length studies Joint survey 76881 Ultrasound, extremity 76882 Ultrasound, extremity, limited 76885 Ultrasound, infant hips 76886 Ultrasound, infant hips, limited Pain Specialists (physiatrists, 72275* Epidurography anesthesiologists, neurologists, 76000 and neurosurgeons) 77002, 77003* Fluoroscopic guidance Pediatricians 71010 to 71030 Chest imaging AIUM accreditation in musculoskeletal ultrasound
Podiatrists 73620, 73630, 73650, 73660 Lower extremity imaging Pulmonologists 71010 to 71030 Chest Imaging Radiation Oncologists 77012 CT guidance for needle placement 77014 CT guidance for placement of radiation therapy fields 76873 Prostate volume study for brachytherapy treatment planning 76950 placement of radiation therapy fields 76965 interstitial radioelement application Reproductive Endocrinologists 77052 Computer aided detection, 77057, G0202 Screening Mammography Ultrasound, obstetrical, pelvic 76815**, 76816**, 76817** 76830 to 76857 76970 74740 Rheumatologists 72010 to 72120,72170, 72190 72200 to 72220 73000 to 73140, 73500 to 73660 76000, 77002 Ultrasound study, follow-up Hysterosalpingography Spine and pelvis imaging Imaging - Upper and lower extremities Must be fully compliant with MQSA requirements to perform 77073, 77077 76881 76882 76885 76886 Sports Medicine 71100 to 71111 71120, 71130 72010 to 72120 72170, 72190 72200 to 72220 73000 to 73140 73500 to 73660 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
Urologists 76775 Ultrasound, retroperitoneal, limited 76870, 76872 Ultrasound, scrotum, transrectal 76873 Prostate volume study for brachytherapy treatment planning Ultrasound guidance for biopsy 76965 Ultrasound guidance for interstitial radioelement placement 76857 Ultrasound, pelvic, limited or follow up Vascular Neurology 75600 75660 75662 75665 75671 75676 75680 75685 75894 75896 75898 76125 Vascular Surgeons 77001 76937 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