Commonwealth of Massachusetts Executive Office of Health and Human Services Division of Medical Assistance 600 Washington Street Boston, MA 02111 MassHealth Diagnostic and Surgical Facility Bulletin 5 August 2000 TO: Diagnostic Facilities Participating in MassHealth FROM: Jean C. Sullivan, Acting Commissioner RE: REVISED LIST OF SERVICE CODES AND DESCRIPTION (1999 and 2000 HCPCS) Background The Division of Health Care Finance and Policy has adopted rates for diagnostic and surgical facilities that are effective for services provided on or after July 1, 2000. The Division of Medical Assistance (Division) will pay freestanding MRI centers only for the service codes listed in this bulletin. Services must be provided in accordance with standards developed by the American College of Radiology (ACR). The Division will review claims to identify whether the services were provided for the recommended clinical condition based on the ACR appropriateness criteria. Billing Information The Division of Health Care Finance and Policy has established a global rate, a professional component rate, and a technical component rate for each MRI or magnetic resonance angiography (MRA) service listed in this bulletin. The Division will pay freestanding MRI centers either the global rate or the technical component rate of the service provided. To bill for the technical component, add the modifier “TC” to the end of the service code on the claim form 5. The Division will pay the professional component of the service to physician providers only. The Division will not pay freestanding MRI centers separately for paramagnetic contrast material (e.g., gadolinium). Payment for paramagnetic contrast material is considered bundled into the payment for the MRI or MRA service. MassHealth Diagnostic and Surgical Facility Bulletin 5 August 2000 Page 2 Individual Consideration A number of service codes are designated as I.C. (individual consideration) in the service descriptions of this bulletin. A radiology report with the radiologist interpretation must accompany the freestanding MRI center’s claim form when billing for I.C. services. The Division will determine appropriate payment for an individual-consideration service based on the documentation submitted to support the use of the service code. If the documentation is illegible or incomplete, the Division will deny the claim with the appropriate denial code. Prior Authorization The Division requires the physician ordering the MRI to obtain prior authorization for those services designated “P.A.” in the service descriptions of this bulletin. No payment will be made for these services unless prior authorization has been obtained from the Division before the delivery of services. The Division will not grant retroactive prior authorization requests. A prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as, but not limited to, member eligibility or the availability of other health insurance payment. To request prior authorization, physicians must follow the billing instructions in Subchapter 5 of the Physician Manual (Section 512). Service Codes for Freestanding MRI Centers Freestanding magnetic resonance imaging centers may bill the Division for either the global or technical component of the following MRI/MRA MRI Centers scans. Service Code Description 70336 Magnetic resonance (e.g., proton) imaging, temporomandibular joint (P.A.) 70540 Magnetic resonance (e.g., proton) imaging, orbit, face, and neck 70541 Magnetic resonance angiography, head and/or neck, with or without contrast material(s) (I.C.) 70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material 70552 with contrast material(s) 70553 without contrast material, followed by contrast material(s) and further sequences MassHealth Diagnostic and Surgical Facility Bulletin 5 August 2000 Page 3 Service Codes for Freestanding MRI Centers (cont.) Service Code Description 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) (I.C.) 72141 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material 72142 with contrast material(s) 72146 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material 72147 with contrast material(s) 72148 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material 72149 with contrast material(s) 72156 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical 72157 thoracic 72158 lumbar 72196 Magnetic resonance (e.g., proton) imaging, pelvis 73220 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint 73221 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity 73720 Magnetic resonance (e.g., proton) imaging, lower extremity, other than joint 73721 Magnetic resonance (e.g., proton) imaging, any joint of lower extremity 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) (I.C.) 74181 Magnetic resonance (e.g., proton) imaging, abdomen 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) (I.C.) 75552 Cardiac magnetic resonance imaging for morphology; without contrast material MassHealth Diagnostic and Surgical Facility Bulletin 5 August 2000 Page 4 Service Fees If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. Rates for freestanding magnetic resonance imaging centers are found in 114.3 CMR 18.00: Radiology. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: (617) 727-2834’ Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: (617) 988-3100