Revisions to the HIP Diagnostic Imaging Policy for Ultrasound

Date Issued: 5/29/2015

The HIP Diagnostic Imaging Self-Referral Payment Policy has recently been updated. Complete information is available in the EmblemHealth Provider Manual.

The HIP diagnostic imaging Self-Referral Payment policy promotes the appropriate use of diagnostic imaging and designates certain imaging procedures that are payable to EmblemHealth/HIP primary care physicians, specialty physicians and other health care professionals by provider practice specialty. It also indicates the minimum accreditation requirements for certain imaging procedures.

New for 2015: Specialists performing ultrasound guidance in their office will be required to have active accreditations and/or certifications, as follows:

Changes effective with date of service 9/1/15

Head/Neck Surgeons (ENT, Otolaryngologist) will be required to obtain accreditation from the American Institute of Ultrasound in Medicine (AIUM), in the dedicated head and neck module to perform the following studies:

  • 76536, head and neck ultrasound
  • 76942, ultrasonic guidance for biopsy

Urologists will be required to obtain accreditation from the AIUM in the dedicated urologic module to perform the following studies:

  • 76775, ultrasound, retroperitoneal, limited
  • 76870, ultrasound, scrotum
  • 76872, ultrasound, transrectal
  • 76873, ultrasound, prostate volume study
  • 76942, ultrasonic guidance biopsy
  • 76857, ultrasound pelvic, limited

Podiatrists will be required to obtain accreditation from the AIUM in dedicated musculoskeletal ultrasound to perform the following studies:

  • 76942, ultrasonic guidance for needle placement
  • 76881, ultrasound extremity
  • 76882, ultrasound, extremity, limited

General Surgeons will be required to obtain accreditation/certification from:

1) Physicians must be certified in breast ultrasound by the American Society of Breast Surgeons (ASBS)

AND;

2) Facilities must have accreditation from the ASBS for Breast Ultrasound and Ultrasound Guided Breast Biopsy;

OR

2a) Accreditation by the American College of Radiology (ACR) in Breast Ultrasound and Ultrasound Guided Breast Biopsy module;

OR

2b) Accreditation by the (AIUM) in Interventional Breast Ultrasound for the following studies:

    • 76942, ultrasonic guidance for needle placement
    • 76641, breast ultrasound, completed
    • 76642, breast ultrasound, limited

Changes effective with date of service 1/1/16

Endocrinologists will be required to obtain accreditation from AIUM in thyroid/parathyroid ultrasound for the following studies:

  • 76942, ultrasonic guidance for needle placement
  • 76536, thyroid ultrasound

The AIUM accepts applications on a year-round basis. The review process takes approximately 12 weeks from the date the application is considered complete, to receive a finding’s report.

The ACR accepts applications on a year-round basis. The review process takes four to six months from the date of receipt of a completed application. ASBS accepts applications on a year-round basis. It is a six-to-eight week process from the date of receipt of a completed application.

If you wish to perform the ultrasound studies outlined above, we urge you to begin the accreditation process as soon as possible. Claims will be denied if requirements are not met within the timeframe outlined above.