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  • Radiology Privileging > Radiology Privileging Program Overview

    There are many clinical reasons physicians other than radiologists must perform in-office imaging as part of their diagnostic and treatment plans. We have radiology privileging protocols to make imaging services available when rendered by physicians other than radiologists.

    This chapter includes the lists of procedures and associated CPT-4 codes that network physicians other than radiologists can perform for specific benefit plans based on their specialty and network participation.

    This program applies to members with the following benefit plans and to practitioners who service these members:

    • EmblemHealth EPO/PPO
    • GHI
    • Vytra

    Note: GHI HMO members and practitioners are not eligible for this program. Protocols for HIP, EmblemHealth CompreHealth EPO and EmblemHealth Medicare HMO appear in the HIP Outpatient Diagnostic Imaging Self-Referral Payment Policy chapter.

    For physicians to perform radiological procedures within their specialty, they must have the appropriate certifications or accreditations, as noted in the Radiology Privileging by Specialty charts in this chapter. Certain procedures require prior approval. When radiological procedures are performed outside the physician’s specialty or when appropriate prior approval is not obtained, claims for such services will be denied, with no liability to the member.

    The charts below detail the inpatient, outpatient and office-based radiology services for which reimbursement will be made when performed by physicians other than radiologists.

    GHI and EmblemHealth EPO/PPO Radiology Privileging by Specialty

    GHI and EmblemHealth EPO/PPO
    Radiology Privileging By Specialty
    PHYSICIAN TYPE CPT-4 CODE CPT-4 DESCRIPTION

    Primary Care Physicians (includes Internal Medicine, Family Practice, General Practice MD, General Practice DO, Geriatrics, Preventive Medicine, Screening Center)

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    Allergists

    74000-74022

    Abdomen Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    Chiropractors

    72010, 72040, 72069, 72070, 72080, 72100

    Spine Imaging

    Dermatologists

    77401

    Radiation Treatment Delivery

    Emergency Medicine

    74000-74022

    Abdomen Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    Endocrinologists

    77080, 77081

    DEXA Studies, Bone Densitometry

    76942

    Ultrasonic Guidance

    76536

    Thyroid Ultrasound

    71010-71023

    Chest Imaging

    74000-74022

    Abdomen Imaging

    Gastroenterologists

    76975

    Endoscopic Ultrasound

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    Gynecological Oncology

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    77057

    Screening Mammography

    77014

    CT Guidance

    76830, 76856, 76857

    Nonobstetrical Ultrasounds, Pelvis

    76873

    Ultrasound, Transrectal

    76930, 76941, 76945, 76946, 76950

    Ultrasonic Guidance

    Gynecology

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    77057

    Screening Mammography

    77014

    CT Guidance

    76830, 76856, 76857

    Non-Obstetrical Ultrasounds, Pelvis

    76930, 76941, 76945, 76946

    Ultrasonic Guidance

    Hand Surgeons

    73090-73140

    Upper Extremity Imaging

    76000-76010

    Fluoroscopy

    77073

    Bone Length Study

    77077

    Joint Survey

    77080, 77081

    DEXA Studies, Bone Densitometry

    Hematology

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    Infectious Disease

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    Neonatology/Perinatology

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    76506, 76511-76529

    Echoencephalography

    76604, 76645

    Chest Ultrasound

    76801-76812, 76815-76819, 76825-76828

    Obstetrical Ultrasounds, Pelvis

    76830-76857

    Nonobstetrical Ultrasounds, Pelvis

    76930-76946

    Ultrasonic Guidance

    Nephrology

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    76770, 76775

    Retroperitoneal Ultrasound

    Neurology

    71010-71030

    Chest Imaging

    74000-74022

    Abdomen Imaging

    70010-70553, 70557-70559

    Head/Neck Imaging

    72010-72120

    Spine Imaging

    Obstetrics and Gynecology

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    77057

    Screening Mammography

    76801-76812, 76815-76819, 76825-76828

    Obstetrical Ultrasounds, Pelvis

    76830, 76856, 76857

    Nonobstetrical Ultrasounds, Pelvis

    76930, 76941, 76945, 76946

    Ultrasonic Guidance

    Oncology

    71010-71023

    Chest Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    74000-74022

    Abdomen Imaging

    77014

    CT Guidance

    76873

    Ultrasound, Transrectal

    76950

    Ultrasonic Guidance

    Ophthalmologists and Optometrists

    77014

    CT Guidance

    76506, 76511-76529

    Ophthalmic Ultrasound

    Oral Surgeons

    70100, 70110, 70140, 70150

    Mandible/Facial Bone Imaging

    70300, 70310, 70320

    Teeth Imaging

    70350

    Cephalogram

    70355

    Orthopantogram

    Otolaryngologists

    70010, 70015, 70030-70220, 70140, 70250-70320, 70332, 70336*, 70350, 70355, 70360, 70370, 70371, 70373, 70380, 70390, 70496*

    Head/Neck Imaging

    Pediatrics

    71010-71023

    Chest Imaging

    74000-74022

    Abdomen Imaging

    Perinatology

    74000-74022

    Abdomen Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    77057

    Screening Mammography

    76604, 76645

    Chest Ultrasound

    76801-76812, 76815-76819, 76825-76828

    Obstetrical Ultrasounds, Pelvis

    76830, 76831, 76856, 76857

    Nonobstetrical Ultrasounds, Pelvis

    76930, 76932, 76936, 76937, 76940, 76941, 76945, 76946

    Ultrasonic Guidance

    Physical Medicine and Rehabilitation

    70360-70390

    Head/Neck Imaging

    72010-72120, 72170, 72190, 72200-72220

    Spine/Pelvis Imaging

    73000-73140

    Upper Extremities Imaging

    73500-73660

    Lower Extremities Imaging

    74000-74022

    Abdomen Imaging

    Podiatrists, Podiatric Surgeons, Podiatric Orthopedists

    73600, 73610, 73620, 73630, 73650, 73660

    Lower Extremities Imaging

    Pulmonologists

    71010-71023

    Chest Imaging

    74000-74022

    Abdomen Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    76700-76775

    Ultrasound Abdomen/Retroperitoneum

    Reproductive Endocrinologists

    71010-71023

    Chest Imaging

    74000-74022

    Abdomen Imaging

    77080, 77081

    DEXA Studies, Bone Densitometry

    76801-76812, 76818, 76819, 76825-76828

    Obstetrical Ultrasounds, Pelvis

    76830-76857

    Nonobstetrical Ultrasounds, Pelvis

    76930-76941, 76945-76948

    Ultrasonic Guidance

    Rheumatologists

    71010-71030

    Chest Imaging

    72010-72120, 72170, 72190, 72200-72285, 72291

    Spine/Pelvis Imaging

    73000-73140

    Upper Extremities Imaging

    73500-73660

    Lower Extremities Imaging

    74000-74022

    Abdomen Imaging

    76000, 76001, 76010, 77002, 77003

    Fluoroscopic Guidance

    77071, 77072, 77073

    Bone/Joint Studies

    77077

    Joint Survey

    Urologists

    74000-74022

    Abdomen Imaging

    74400, 74425, 74430, 74450, 74455

    Ultrasound, Urinary Tract

    76000

    Fluoroscopy

    76870, 76872, 76873

    Ultrasound Genitalia

    76942

    Ultrasonic Guidance

    *These procedures require prior approval.

    Vytra Radiology Privileging by Specialty

    Vytra
    Radiology Privileging By Specialty
    PHYSICIAN TYPE CPT-4 CODE CPT-4 DESCRIPTION

    Cardiology

    78414-78499

    Cardiac Nuclear Medicine Studies

    General Surgery

    76942

    Echo Guide for Biopsy

    76942

    Ultrasonic Guidance

    Gynecology

    76830

    Transvaginal Ultrasound

    76998

    Ultrasonic Guidance

    74740

    Hysterosalpingography

    Hand Surgery
    (practitioner must be certified in Hand Surgery by the American Board of Medical Specialties)

    Those radiology procedures within the scope of the specialty area

    Obstetrics and
    Gynecology

    76805-76831

    Pregnancy-Related Sonograms

    76856

    Pelvic Ultrasound, Nonobstetrical

    76941-76946

    Needle Guidance Sonograms Used for Amniocentesis

    76998

    Ultrasonic Guidance

    Oncology

    71010, 71020

    Chest X-rays

    Orthopedics

    Those radiology procedures within the scope of the specialty area

    Pulmonology

    71010, 71020

    Chest X-rays

    Rheumatology

    Those radiology procedures within the scope of the specialty area

    Urology

    76942, 76872, 76950, 77778, 78730

    Ultrasound Guidance for Needle Biopsy

    Vytra reviews this list on an ongoing basis and revises it as appropriate.

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    Glossary terms found on this page:

    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.

    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.

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    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.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    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.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    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.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

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

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

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

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