Services from the Radiology Section of CPT Billed with Other Services

The guidelines described below apply to claims processed under the new claims processing system. The guidelines should be used for filing all private business claims.

The code edit changes described in the guidelines below will not override HMSA's existing medical policies.

Modifiers

When billing for radiologic services with other services, it is important to bill accurately.

When two or more CPT codes are billed together, a modifier code(s) may be appended to one or more of the codes to clarify the services rendered. Modifiers that may be used include TC, 26, 59, 76,77, LT, RT and other site specific modifiers. Practitioners are urged to familiarize themselves with the criteria listed in CPT and in the following policies.

• Modifier Code 59
• Modifier Code 76
• Radiology and Nuclear Medicine - Coding Guidelines

Modifier codes should only be used when the service meets the criteria described in CPT and HMSA's policies. HMSA will perform post payment reviews of modifier usage as needed to verify modifiers were used as described. If post payment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.

Specific edits

The following code edits apply to services from the Radiology section of CPT billed with other services.

If the code in the left column is billed with any of the codes in the right column, one of the codes will deny. The reason for the denial may vary because:

• The codes may be mutually exclusive. Mutually exclusive procedures are two or more procedures that are usually not performed during the same patient encounter on the same date of service.
• Multiple codes may have been billed, which taken together are more accurately described by a more comprehensive procedure code.
• The code may be incidental to another code. An incidental procedure is a procedure carried out at the same time as a more complex primary procedure; however, the incidental procedure requires little additional physician resources and/or is clinically integral to the performance of the primary procedure.

However, unless otherwise indicated, a modifier may be used to request separate payment, if criteria for the use of the modifier are met.

Codes from the Radiology section billed with other codes from the same section

Codes from the Radiology section billed with codes from the Surgery section

Codes from the Radiology section billed with codes from the Medicine section

Note: The above lists are not all inclusive and are subject to change.

Revision History