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  • HIP Outpatient Diagnostic Imaging Referral Payment Policy > HIP Outpatient Diagnostic Imaging Self Referral Payment Policy

    HIP Outpatient Diagnostic Imaging Self-Referral Payment Policy

    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 HIP payment policies below designate which imaging procedures shall be payable by HIP (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.


    2015 HIP Outpatient Diagnostic Imaging Self-Referral Payment Policy
    Effective January 1, 2015

    Provider Specialty

    CPT Codes

    Description

    Accreditation
    Requirement(s)

    Primary Care Physicians (includes Internal Medicine, Family Practice)

    71010 -71030

    Chest imaging

    No additional requirements

    77080, 77081, 770853

    DEXA studies, bone densitometry
    933031, 933041, 933061- 933081 Transthoracic echocardiography 1. National Board of Echocardiography (NBE) certification
    2. Laboratories accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (IAC Echocardiography) 3
    933501, 933511

    Doppler echocardiography, add on codes

    Cardiologists (includes Cardiovascular Disease, Interventional Cardiologists, Cardiac Electrophysiologists)

    71010 - 71030 Chest imaging

    No additional requirements

    76930 Ultrasonic guidance for pericardiocentesis
     76932 Ultrasonic guidance for endomyocardial biopsy
     933031, 933041, 933061– 933081 Transthoracic echocardiography 1. Cardiology certification by the American Board of Internal Medicine (ABIM) or American Osteopathic Board of Internal Medicine (AOBIM)
    2. Laboratories accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (IAC Echocardiography) 3
     93320, 93321, 93325 Doppler echocardiography, add on codes
     933501, 933511 Stress echocardiography

    Cardiologists, Nuclear

    784511, 784521, 784531, 784541 Myocardial perfusion imaging

    1. Certification by the American Board of Radiology (ABR), American Board of Nuclear Medicine (ABNM) or Certification Board of Nuclear Cardiology (CBNC)
    2. Laboratories accredited by the Intersocietal Commission for the Accreditation of Nuclear Laboratories (IAC Nuclear/PET)3 or American College of Radiology (ACR)

    784661, 784681, 784691 Myocardial infarction scans
    784721, 784731, 784811, 784831, 784941 Cardiac blood pool imaging
    76930 Ultrasonic guidance for pericardiocentesis
    76932 Ultrasonic guidance for endomyocardial biopsy

    Pediatric Cardiologists

    768252 - 768282 Echocardiography, fetal

    1. Certification in pediatric cardiology by the American Board of Pediatrics
    2. Laboratories accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (IAC Echocardiography) 3

    715551 MRA chest
    755571 - 755631 Cardiac MRI
    71010 - 71030 Chest imaging
    76930 Ultrasonic guidance for pericardiocentesis
    76932 Ultrasonic guidance for endomyocardial biopsy
    933031, 933041, 933061 to 933081 Stress echocardiography
    933501 , 93351 Transesophageal echocardiography
    93320, 93321, 93325 Doppler echocardiography, add on codes

    Chiropractors

    72010, 72040, 72069, 72070, 72080, 72100

    Spine imaging

    No additional requirements

    Colon and Rectal Surgeons

    76872

    Ultrasound, transrectal

    Must be board certified by the American Board of Colon and Rectal Surgery (ABCRS) to perform this ultrasound

    76942 Ultrasonic guidance for biopsy only

    Endocrinologists

    77080,77081, 770853

    DEXA studies, bone densitometry

    No additional requirements

    76536

    Thyroid ultrasound

    Endocrine Certification in Neck Ultrasound (ECNU) from the American Association of Clinical Endocrinologist (AACE)
    5 Effective 1/1/16: American Institute of Ultrasound in Medicine (AIUM) accreditation in thyroid/ parathyroid ultrasound

    76942 Ultrasonic guidance for biopsy

    Gastroenterologists

    76975

    Endoscopic ultrasound

    No additional requirements

    General Surgeons

    75962 Transluminal balloon angioplasty

    No additional requirements

    Breast Surgeons

    76942

    Ultrasonic guidance for biopsy

    4 Effective 9/1/15: For breast ultrasound and ultrasound guided breast biopsy: 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 Accredited by the Am. College of Radiology in breast ultrasound and ultrasound guided biopsy; or Accredited by AIUM in interventional breast ultrasound

    766413

    Breast ultrasound, complete

    766423 Breast ultrasound, limited

    Geriatricians

    71010 - 71030

    Chest imaging

    No additional requirements

    933031, 933041, 933061 to 933081

    Transthoracic echocardiography

    Non-cardiologists:
    1. National Board of Echocardiography (NBE) certification
    2. Laboratories accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (IAC Echocardiography) 3

    93320, 93321, 93325 Doppler echocardiography, add on codes

    Hand Surgeons

    76000

    Fluoroscopy

    No additional requirements

    73100 - 73140 Upper extremity imaging

    Head and Neck Surgeons (includes ENT, Otolaryngologists)

    76942, 76536

    Ultrasonic guidance for biopsy only

    No additional requirements 5 Effective 9/1/15: AIUM accreditation in head and neck ultrasound

    Hematologist/Oncologists Medical Oncologists Oncologists

    71010 - 71030

    Chest imaging

    No additional requirements

    Maternal and Fetal Medicine

    77052 Computer-aided detection of radiographic images

    Must be fully compliant with Mammography Quality Standards Act (MQSA) requirements to perform screening mammography

    77057, G0202 Screening mammography
    770633 Screening tomosynthesis

    74740

    Hysterosalpingography

    No additional requirements

    77080, 77081, 770853 DEXA studies, bone densitometry
    768152, 768162, 768172, 768202, 768212, 76830 – 76857, 76930, 76941, 76942, 76945, 76946, 76948 Ultrasound: obstetrical, pelvic, guidance
    768012, 768022, 768052, 768102, 768112, 768122, 768132, 768142, 768182, 768192, 768202, 768212, 768252, 768262, 768272, 768282 Ultrasound: obstetrical/pelvic guidance AIUM/ACR Accreditation
    76970 Ultrasound study, follow-up
    93325 Doppler echocardiography, add on

    Nephrologists

    75791 Angiography arteriovenous shunt, radiological supervision and interpretation

    No additional requirements

    75978 Venous angioplasty, radiological supervision and interpretation
    77021 MR guidance for needle placement
    77012 CT scan for needle biopsy
    77002 Needle localization by x-ray
    76942 Ultrasonic guidance for biopsy
    759623 Transluminal balloon angioplasty

    Nuclear Medicine

    780121, 780131, 780141, 780151, 780161, 780181, 780201, 780701, 780711, 780721, 780751, 781021, 781031, 781041, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 781851, 78190, 78191, 781951, 782011, 782021, 782051, 782061, 782151, 782161, 782261, 782271, 782301, 782311, 782321, 782581, 782611, 782621, 782641, 78270, 78271, 78272, 782781, 782821, 782901, 782911, 783001, 783051, 783061, 783151, 783201, 785791, 785801, 78582 1, 785971,785981, 786001, 786011, 786051, 786061, 786071, 786101, 786301, 786351, 786451, 786471, 786501, 786601, 787001, 787011, 787071, 787081, 787091, 787101, 787251, 787301, 787401, 787611, 788001, 788011, 788021, 788031, 788041, 788051, 788061, 788071, 78808, 788111, 788121, 788131, 788141, 788151, 788161

    Nuclear medicine studies

    Physicians certified by the American Board of Radiology (ABR) or the American Board of Nuclear Medicine (ABNM)

    Obstetrics and Gynecology 77052 Computer aided detection of radiographic images

    No additional requirements

    77057, G0202 Screening Mammography
    770633 Screening tomosynthesis
    77080, 77081, 770853 DEXA studies, bone densitometry
    74740 Hysterosalpingography
    76830 to 76857, 768152, 768162, 768172 Ultrasound : obstetrical, pelvic
    76930 Ultrasound study, follow-up Guidance
    76941 Ultrasonic guidance for fetal transfusion or cordocentesis
    76945 Ultrasonic guidance for chorionic villus sampling
    76946 Ultrasonic guidance for amniocentesis
    76948 Ultrasonic guidance for aspiration of ova
    76970 Ultrasound study, follow-up

    768012, 768022, 768052, 768102, 768112, 768122, 768132, 768142, 768182, 768192, 768202, 768212, 768252, 768262, 768272, 768282

    Ultrasound: obstetrical, pelvic
    93325

    Doppler echocardiography

    Oral Surgeons

    70100, 70110, 70140, 70150 Mandible and facial bone imaging

    No additional requirements

    70300, 70310, 70320 Teeth imaging
    70328, 70330 TMJ imaging
    70350 Cephalogram, orthodontic
    70355 Orthopantogram

    Orthopedists (includes Pediatric Orthopedists, Orthopedic Surgeons and Pediatric Orthopedic Surgeons)

    71100 - 71111

    Radiologic examination, ribs

    No additional requirements

    71120 - 71130 Radiologic examination, sternum
    72010 - 72120,72170, 72190 72200 - 72220 Spine and Pelvis imaging
    73000 - 73140, 73500 - 73660 Imaging to Upper and lower extremities
    76000, 77002, 77003 Fluoroscopy
    77071 Radiologic examination, any joint
    77073 Bone length studies
    77077 Joint survey
    76881 Ultrasound, extremity

    AIUM accreditation in musculoskeletal ultrasound

    76882 Ultrasound, extremity, limited
    76885 Ultrasound, infant hips
    76886 769423 Ultrasound, infant hips, limited Ultrasonic guidance for needle placement

    Pain Specialists (includes Physiatrists, Anesthesiologists, Neurologists, Neurosurgeons, Physical Medicine and Rehabilitation)

    72275

    Epidurography, radiological supervision and interpretation

    No additional requirements

    76000, 77002, 77003 Fluoroscopy

    Pediatricians

    71010–71030

    Chest imaging

    No additional requirements

    Podiatrists

    73600, 73610, 73620, 73630, 73650, 73660

    Lower extremity imaging

    No additional requirements

    769424 Ultrasonic guidance for needle placement
    768814 Ultrasound, extremity
    768824 Ultrasound, extremity, limited

    Pulmonologists

    71010–71030

    Chest imaging

    No additional requirements

    Radiation Oncologists

    77012 Computed tomography guidance for needle placement

    No additional requirements

    77014 Computed tomography guidance for placement of radiation therapy fields
    76873 Prostate volume study for brachytherapy treatment planning
    76950 Ultrasonic guidance for placement of radiation therapy fields
    76965 Ultrasonic guidance for interstitial radioelement application
    76942 Ultrasonic guidance for biopsy only

    Reproductive Endocrinologists

    77052 Computer aided detection of radiographic images

    Must be fully compliant with MQSA requirements to perform screening mammography

    77057, G0202 Screening Mammography
    770633 Screening tomosynthesis

    77080, 77081, 770853

    DEXA studies, bone densitometry

    No additional requirements

    768152, 768162, 768172, 76830 to 76857 Ultrasound – obstetrical, pelvic
    76948 Ultrasonic guidance for aspiration of ova
    76970 Ultrasound study, follow-up
    74740 Hysterosalpingography
    768012, 768022, 768052, 768102, 768112, 768122, 768132, 768142, 768182, 768192, 768202, 768212, 768252, 768262, 768272, 768282

    Ultrasound: obstetrical, pelvic, guidance

    AIUM/ACR Accreditation

    76941 Ultrasonic guidance for fetal transfusion or cordocentesis
    76942 Ultrasonic guidance for biopsy
    76945 Ultrasonic guidance for chorionic villus sampling
    76946

    Ultrasonic guidance for amniocentesis

    93325 Doppler echocardiography, add on

    Rheumatologists

    72010 - 72120,72170, 72190 72200 - 72220

    Spine and pelvis imaging

    No additional requirements

    73000 - 73140, 73500 - 73660 Imaging- Upper and lower extremities
    76000, 77002 Fluoroscopy
    77073, 77077 Bone length studies, joint survey
    77080, 77081, 770853 DEXA studies, bone densitometry

    76881

    Ultrasound, extremity

    AIUM accreditation in musculoskeletal ultrasound

    76882 Ultrasound, extremity, limited
    76885 Ultrasound, infant hips
    76886 Ultrasound, infant hips, limited
    76942 3 Ultrasonic guidance for needle placement

    Sports Medicine

    71100 - 71111 Radiologic examination, ribs

    Board certification in sports medicine and combined fellowship, residency and training in sports medicine of at least four years

    71120 - 71130 Radiologic examination, sternum
    72010 - 72120, 72170, 72190, 72200 - 72220 Spine and pelvis imaging
    73000 - 73140, 73500 - 73660 Imaging to upper and lower extremities

    76881

    Ultrasound, extremity

    AIUM accreditation in dedicated musculoskeletal ultrasound

    76882 Ultrasound, extremity, limited
    769423 Ultrasonic guidance for needle placement

    Urologists

    74455 Urethrocystography

    No additional requirements

    76775 Ultrasound, limited 4 Effective 9/1/15: AIUM accreditation in urologic ultrasound
    76870, 76872, 76873 Ultrasounds - scrotum, Transrectal Prostate volume study for brachytherapy treatment planning
    76942 Ultrasonic guidance for biopsy only
    76857 Ultrasound pelvic limited or follow up

    Vascular Neurology

    76125 Cineradiography/video radiography

    ABMS Certification in Vascular Neurology

    75898 Angiography through existing catheter
    75896 Transcatheter therapy, infusion
    75894 Transcatheter therapy, embolization
    75685 Angiography, vertebral, cervical and/or intracranial
    75680 Angiography, carotid, cervical, bilateral
    75676 Angiography, carotid, cervical, unilateral
    75671 Angiography, carotid, cerebral, bilateral
    75665 Angiography, carotid, cerebral, unilateral
    75662 Angiography, external carotid, bilateral, selective
    75660 Angiography, external carotid, unilateral, selective
    75600 Aortography, thoracic, without serialography

    Vascular Surgeons

    77001

    Fluoroscopic guidance for central venous access device

    No additional requirements

    76937 US guidance for vascular access

    Note: This policy does not apply to IPA services rendered in Putnam and Ulster Counties

    1 These procedures require pre-certification; call 1-866-417-2345

    2 Any studies beyond three require pre-certification; call 1-866-417-2345

    3 Procedure Code Changes effective 1/1/15

    4 Changes effective 9/1/15:

    • General Surgeons must have individual ASBS certification; facilities must have accreditation from ASBS, or ACR or AIUM
    • Head and Neck Surgeons must have accreditation in Head and Neck Ultrasound from AIUM
    • Podiatrist must have accreditation in Dedicated Musculoskeletal Ultrasound from AIUM
    • Urologist must have accreditation in Urologic Ultrasound from AIUM

    5 Changes Effective: 1/1/16:

    • Endocrinologist must have accreditation in Dedicated Thyroid/Parathyroid Ultrasound from AIUM

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    Glossary terms found on this page:

    Organized originally in 1933 as the Advisory Board of Medical Specialties, the ABMS (1970), in collaboration with the American Medical Association (AMA), is the recognized certifying agent for establishing and maintaining standards of medical specialization and pattern of training.

    An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    A process by which a physician who has been tested for proficiency in a medical specialty or subspecialty, by a medical specialty board, has passed those tests and been certified as proficient in that medical specialty.

    A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    Treatment of disease by X-ray, radium, cobalt or high energy particle sources.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

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