Provider Manual

Chapter 21: HIP Outpatient Diagnostic Imaging Referral Payment Policy

Our diagnostic imaging payment policy as it applies to services performed in an office setting (POS 11). The policy designates which imaging procedures will be reimbursed (subject to the member’s benefit plan) according to practitioner specialty.

 

 

There are many clinical reasons practitioners other than radiologists perform in-office imaging as part of their diagnostic and treatment plans. We have radiology and cardiology imaging privileging protocols for HIP/HIPIC-underwritten Benefit Plans that are administered by EmblemHealth, which include Commercial (including GHI HMO, Vytra branded plans), state-sponsored and Medicare plans. These privileging protocols make up the Diagnostic Imaging Self-Referral Payment Policy. They are designed to promote the appropriate use of diagnostic imaging by clinicians in office settings.

 

The payment policy applies to services performed in an office setting (POS 11). It is based on a careful review of the literature and standards of the American Society of Echocardiography (ASE), Intersocietal Accreditation Commission (IAC), American College of Cardiology (ACC) and American Board of Radiology (ABR). The policy designates which imaging procedures will be reimbursed (subject to the member’s benefit plan) according to practitioner specialty. It also describes the minimum accreditation and certification requirements.

 

For providers to perform imaging procedures within their specialty, they must meet and maintain the minimum certification requirements. These requirements are listed in the Outpatient Imaging Self-Referral Payment Policy chart in this chapter. When imaging procedures are performed outside the practitioner’s specialty or when the practitioner fails to maintain the minimum certification requirements or obtain Prior Approval when required, claims for such services will be denied, with no liability to the member.

Excluded from this payment policy are HIP/HIPIC-underwritten Benefit Plans members assigned to a Montefiore, HealthCare Partners (HCP) or AdvantageCare Physicians (ACPNY) PCP. These members can be identified by their member ID card or through member eligibility information on our secure website. Protocols for GHI-underwritten plans are contained within the Radiology Privileging chapter.

EmblemHealth will reimburse cardiologists for approved echocardiography studies (CPT codes 93303, 93304, 93306, 93307, 93308, 93350 and 93351) and nuclear studies (CPT codes 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483 and 78494), but only if they are performed at accredited locations. Prior approval rules continue to apply where applicable.

 

Accreditation for echocardiography studies requires both:

  1. Cardiology board certification of the physician by the American Board of Internal Medicine (ABIM) or American Osteopathic Board of Internal Medicine (AOBIM) and
  2. That services are rendered in laboratories accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL)

 

Accreditation for nuclear studies requires both:

  1. Certification of the physician by the American Board of Radiology (ABR), American Board of Nuclear Medicine (ABNM) or Certification Board of Nuclear Cardiology (CBNC) and
  2. That services are rendered in laboratories accredited by the Intersocietal Commission for the Accreditation of Nuclear Laboratories (ICANL) or American College of Radiology (ACR)

Participating practitioners will be reviewed for active accreditation. For echocardiography services, the review will appear in the national databases of ICAEL and ICANL. For nuclear medicine/nuclear cardiology services, the review will appear in the national database of ACR. All other specialties must email their certification(s) directly to provideraccreditations@evicore.com. For more information about accreditation status or certificate submissions, email provideraccreditations@evicore.com or call 1-800-918-8924, ext. 27901.

 

For information on accreditation requirements and instructions for submitting an application for accreditation, refer to the websites of the accrediting organizations below:

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.

View 2015 HIP Outpatient Diagnostic Imaging Self-Referral Payment Policy page here