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Library: Policy

317:30-5-24. Radiology

Revised 6-25-11

(a) Outpatient and emergency department.

  • (1) The technical component of outpatient radiological services performed during an emergency department visit is covered.

  • (2) The professional component of x-rays performed during an emergency department visit is covered.

  • (3) Ultrasounds for obstetrical care are paid in accordance with provisions found at OAC 317:30-5-22(b)(2)(A-C).

  • (4) Payment is made for charges incurred for the administration of chemotherapy for the treatment of medically necessary and medically approved procedures.  Payment for radiation therapy is limited to the treatment of proven malignancies and benign conditions appropriate for stereotactic radiosurgery (e.g.,gamma knife).

  • (5) Medically necessary screening mammography is a covered benefit.  Additional follow-up mammograms are covered when medically necessary.

(b) Inpatient procedures.  Inpatient radiological procedures are compensable if done on a referral basis.  Claims for inpatient interpretations by the attending physician are not compensable unless the attending physician reads interpretations for the hospital on all patients.

(c) Inpatient radiology performed outside of hospital.  When a member is an inpatient but has to be taken elsewhere for an x-ray, such as to an office or another hospital because the admitting hospital did not have proper equipment, the place of service must still be inpatient hospital, since the member is considered to be in the hospital at the time of service.

(d) Radiology therapy management.  Weekly clinical management is based on five fractions delivered comprising one week regardless of the time interval separating the delivery of treatments.  Weekly clinical management must be billed as one unit of service rather than five.

(e) Miscellaneous.

  • (1) Arteriograms, angiograms and aortograms.  When arteriograms, angiograms or aortograms are performed by a radiologist, they are considered radiology, not surgery.

  • (2) Injection procedure for arteriograms, angiograms and aortograms.  The "interpretation only" code and the "complete procedure" code are not both allowed for one of these procedures.

  • (3) Evac-U-Kit or Evac-O-Kit.  Evac-U-Kit and Evac-O-Kit are included in the charge for the Barium Enema.

  • (4) Examination.  Examination at bedside or in operating room allows an additional charge to be made.  Examination outside regular hours is not a covered charge.

  • (5) Supplies.  Separate payment is not made for supplies such as "administration set" used in provision of office chemotherapy.

  • (6) Fluoroscopy or Esophagus study.  Separate charge for fluoroscopy or esophagus study in addition to a routine gastrointestinal tract examination is not covered unless a report is submitted indicating an esophagram was done as a separate procedure.

(f) Magnetic Resonance Imaging, Positron Emission Tomography, and Computed Tomography.  MRI/MRA, PET, and CT/CTA scans are covered when medically necessary.  Documentation in the progress notes must reflect the medical necessity.  The diagnosis code must be shown on the claim.

(g) Placement of radium or other radioactive material.

  • (1) For Radium Application use the appropriate HCPCS code.

  • (2) When a physician supplies the therapeutic radionuclides (implant grains or Gold Seeds) and provides a copy of the invoice, payment is made at 100% of the invoice charges.  Fee must include cost of radium, container, and shipping and handling.

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