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Diagnostic Imaging Privileging by Participating Provider Practice Specialty

Administrative Policy:
Diagnostic Imaging Privileging by Participating Provider Practice Specialty

Effective Date:
November 30, 2009

Last Revised Date:
December 29, 2021

Scope:
The following products are excluded from this policy: Blue Card (ITS Home); Federal Employee Program (FEP), Horizon NJ Health, Medigap, National ASO – Indemnity (out-of-state), National ASO – PPO (out of state).

Policy:
The privileging policy is designed to improve quality and promote appropriate use of diagnostic imaging by primary care physicians, specialty physicians and other health care professionals. The Horizon payment policies below designate which imaging procedures shall be payable by Horizon (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.

Participating primary care physicians, specialty physicians and other health care professional will be reimbursed for only those exams that they are privileged to perform in an office setting. Participating physicians, specialty physicians and other health care professionals are required to comply with Horizon’s radiology/imaging quality standards, Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities.

The list below details the imaging CPT codes that designated physicians, specialty physicians and other health care professionals can perform. Practices consisting of more than one specialty are also privileged in accordance with the privileging information detailed below; privileging is based on the ordering physician specialty. If a practice includes a radiologist for the supervision and interpretation of examinations for which the ordering specialist in that practice is privileged to perform, only those examinations on the privileging list for the specialty of the ordering physician will be reimbursed. Diagnostic imaging services that are not listed under the ordering physician’s specialty must be referred to either a participating freestanding radiology site or a participating hospital outpatient setting. Note: Horizon does not consider a multi-specialty practice with a radiologist on site as a freestanding radiology center. Any examination that is performed outside of the ordering specialist’s privileging will not be reimbursed and will be the liability of the specialty practice. Multi- specialty physician groups and Ambulatory Surgi-Centers will not be permitted to perform advanced imaging procedures. All advanced imaging must be performed in a participating freestanding radiology center or participating hospital outpatient site.

Mobile Imaging Services must comply with our Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities administrative policy and only render services where the provider is specifically contracted to provide imaging services.

As participating primary care physicians, specialty physicians and other health care professionals, you must ensure compliance to the above mentioned policy as this could affect what radiology services you would be privileged to perform. In addition, all licenses are non-transferable; therefore time share, table time or equipment leases other than direct leases with a manufacturer or financing company whether or not on per diem basis is not permitted.

The following products are excluded from this policy: Blue Card (ITS Home); Federal Employee Program (FEP), Horizon NJ Health, Medigap, National ASO – Indemnity (out-of-state), National ASO – PPO (out of state).

Informational Notes:

  1. Specialty privileging includes pediatric specialties unless otherwise noted.
  2. All participating providers, specialist or other health care specialist performing diagnostic or therapeutic imaging are required to comply with Horizon Radiology/Imaging Quality Standards, State and Federal guidelines as well as compliance with ALARA and Image Wisely guidelines/parameters.
  3. All diagnostic radiographic procedures must be performed by an ARRT licensed radiographic technologist or privileged physician.
  4. One (1) unit of CPT code 76942 is allowable for a single patient encounter

References:

  1. American Association of Clinical Endocrinologists (AACE), Endocrine Certification in Neck Ultrasound (ECNU) www.aace.com/college/ECNU/
  2. American Board of Radiology (ABR) www.theabr.org/
  3. American College of Cardiology (ACC) www.acc.org/
  4. American College of Nuclear Medicine (ACNM) www.acnmonline.org/
  5. American College of Radiology (ACR)www.acr.org/
  6. American Osteopathic Board of Radiology (AOBR)www.aocr.org/
  7. American Registry for Diagnostic Medical Sonography (ARDMS) www.ardms.org/
  8. American Registry of MRI Technologists (ARMRIT) www.armrit.org/index.shtml
  9. American Registry of Radiologic Technologists (ARRT) https://www.arrt.org/
  10. American Society of Nuclear Cardiology (ASNC) www.asnc.org/
  11. American Institute of Ultrasound in Medicine (AIUM) www.aium.org/
  12. Canadian Association of Medical Radiation Technologists (CAMRT) www.camrt.ca/
  13. Federal Drug Administration (FDA), Radiation Emitting Products www.fda.gov/Radiation-EmittingProducts/default.htm
  14. International Society of Bone Densitometry (ISCD) www.iscd.org/
  15. Intersocietal Accreditation Commission (IAC) www.intersocietal.org/intersocietal.htm
  16. Intersocietal Commission for the Accreditation of Computed Tomographic Laboratories (ICACTL) http://www.intersocietal.org/ct/
  17. Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) http://www.intersocietal.org/echo/
  18. Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories (ICAMRL) http://www.intersocietal.org/mri/
  19. Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL) http://www.intersocietal.org/nuclear/
  20. Intersocietal Commission for the Accreditation of Vascular Testing (ICAVL) http://www.intersocietal.org/vascular/
  21. Mammography Quality Standards Act (MQSA) https:// www.fda.gov/radiation-emitting-products/regulations-mqsa/mammography-quality-standards-act-mqsa