Radiology Services Reimbursement Policy Being Updated to Include Professional Components
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is updating the current Radiology Services Reimbursement Policy for its commercial products to extend multiple procedure payment reductions (MPPR) to the professional components of secondary and subsequent diagnostic imaging services. The updated policy becomes effective January 15, 2018, and upon that date it will replace the existing policy.
Effective for dates of service on or after January 15, 2018, when multiple diagnostic imaging services are performed for the same commercially insured patient on the same day, during the same outpatient session, and by the same physician or multiple physicians in the same group practice reporting under the same federal tax identification, Blue Cross of NC will consider 100 percent of the allowance for the professional component of the primary procedure and apply MPPR to the policy defined, secondary components. The allowance for the professional components of the second and each subsequent imaging procedure will be considered at 95 percent of the allowed amount for each specific procedure.
By implementing this policy and applying a 5 percent reduction to the professional components of secondary services, we can better align Blue Cross NC with the Centers for Medicare and Medicaid Services (CMS), as well as other industry payers in the management of overlapping services. The application of MPPR on the professional components of secondary diagnostic imaging services has been widely recognized since 2012, with professional components commonly assigned reductions of up to 25 percent. However, CMS revised its policy effective January 1, 2017, which lowered the reductions on the professional components of secondary services from 25 percent to 5 percent. Blue Cross NC must ensure our reimbursement policies are aligned appropriately with industry standards and support our ability to continue offering our customers competitive options for affordable health care coverage. Therefore, Blue Cross NC is adopting a 5 percent MPPR on the professional components of secondary diagnostic imaging services, starting in January 2018.
MPPR will not be applied to the professional components when:
- Second and subsequent professional components are billed as part of a global fee being charged by one provider or provider group.
- Multiple diagnostic imaging procedures are reported using Current Procedural Terminology codes appropriately appended with either modifier (59) or (XE), and in addition to a (PC) or (26) professional component modifier. Modifiers (59) and (XE) can be appropriate to report when documentation supports that a procedure was performed on the same day but not during the same session.
Codes applicable to this policy are available in the existing policy. Additionally, the updated policy will be available for review on the Medical Policy Updates page at bcbsnc.com, on or before November 16, 2017.