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:
January 1, 2023
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:
- Specialty privileging includes pediatric specialties unless otherwise noted.
- 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.
- All diagnostic radiographic procedures must be performed by an ARRT licensed radiographic technologist or privileged physician.
- One (1) unit of CPT code 76942 is allowable for a single patient encounter
Primary Care Physicians: Internal Medicine, Family Practice
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
71045 to 71048 77080** 77081** 77085** |
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93303* 93304* 93306* 93307* 93308* 93319* 93320 93321 93325 |
National Board of Echocardiography (NBE) certification | Intersocietal Accreditation Commission (IAC) in Adult Transthoracic Echocardiography |
* These procedures require prior authorization/pre-service medical necessity review call 1-866-496-6200.
** Reimbursement of DEXA studies are subject to both benefit and appropriateness criteria. See all related policies.
Cardiologists (includes cardiovascular specialist, interventional cardiologist, and cardiac electrophysiologist)
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
33016 33017 33018 33019 71045 to 71048 76932 |
||
93303* 93304* 93306* 93307* 93308* 93350* 93351* 93319* 93320 93321 93325 93352 93880 93922 to 93924 |
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|
* These procedures require prior authorization/pre-service medical necessity review call 1-866-496-6200.
Cardiologists (Nuclear)
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
78451* 78452* 78453* 78454* 78466* 78468* 78469* 78472* 78473* 78481* 78483* 78494* 78496* |
|
|
* These procedures require prior authorization/pre-service medical necessity review call 1-866-496-6200.
Cardiologists, Pediatric
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
33016 33017 33018 33019 71045 to 71048 76825 to 76828 76932 |
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93303* 93304* 93306* 93307* 93308* 93319* 93320 93321 93325 93350* 93351* |
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|
* These procedures require prior authorization/pre-service medical necessity review call 1-866-496-6200.
Chiropractors
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
72040 72070 72080 72100 |
Colon & Rectal Surgeons
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
76872 76942 |
Certification by the American Board of Colon & Rectal Surgery (ABCRS) |
Endocrinologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement | |
76536 76942 77080** 77081** 77085** |
** Reimbursement of DEXA studies are subject to both benefit and appropriateness criteria. See all related policies.
Gastroenterologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
76975 76391 76978 76979 |
General Surgeons
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
76942 76642 76641 |
For breast ultrasound and ultrasound guided breast biopsy:
|
For breast ultrasound and ultrasound guided breast biopsy:
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Geriatricians
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
71045 to 71048 | ||
93303* 93304* 93306* 93307* 93308* 93319* 93320 93321 93325 |
Non-cardiologists:
|
|
* These procedures require prior authorization/pre-service medical necessity review call 1-866-496-6200.
Hand Surgeons
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
76000 73100 73120 73140 |
Head and Neck Surgeons (ENT, otolaryngologist)
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
70210 70220 76536 76942 |
Hematologist/Oncologists Medical Oncologists, Oncologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
71045 to 71048 77080** 77081** 77085** |
** Reimbursement of DEXA studies are subject to both benefit and appropriateness criteria. See all related policies.
Maternal and Fetal Medicine Neonatal/Perinatal Medicine
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
77063 77067 |
|
|
74740 76376 77080** 77081** 77085** 76815 76816 76817 76830 to 76857 76948 |
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76801 76802 76805 76810 76811 76812 76813 76814 76818 76819 76820 76821 76825 76826 76827 76828 76941 76942 76945 76946 93325 |
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** Reimbursement of DEXA studies are subject to both benefit and appropriateness criteria. See all related policies.
Nephrologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
77002 76942 |
Neurologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
93880 |
Nuclear Medicine
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
All 78000 nuclear medicine studies are included in this section, please consult your Provider Manual to determine which nuclear studies require prior authorization/medical necessity review or call eviCore healthcare for assistance 1-866-496-6200. |
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OB/GYN
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
77063 77067 |
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74740 76376 77080** 77081** 77085** 76815 76816 76817 76830 to 76857 76948 |
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76801 76802 76805 76810 76811 76812 76813 76814 76818 76819 76820 76821 76825 76826 76827 76828 76941 76945 76946 93325 |
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** Reimbursement of DEXA studies are subject to both benefit and appropriateness criteria. See all related policies.
Oral Surgeons
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
70100 70110 70140 70150 70300 70310 70320 70328 70330 70350 70355 |
Orthopedists (Including Pediatric Orthopedists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
71100 to 71111 71120 71130 72020 72040 72050 72052 72070 to 72120 72170 72190 72200 to 72220 73000 to 73140 73501 to 73503 73521 to 73523 73525 73551 73552 73560 73562 73564 73565 to 73580 73590 73592 73600 73610 73615 73620 73630 73650 73660 76000 77002 77003 77071 77073 77077 77080** 77081** 77085** |
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76881 76882 76883*** 76885 76886 76942 |
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** Reimbursement of DEXA studies are subject to both benefit and appropriateness criteria. See all related policies.
*** New 2023 AMA addition, CPT 76883 effective 03/01/2023. No Prior Authorization required.
Pain Specialists (physiatrists, anesthesiologists, neurologists, and neurosurgeons)
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
76000 77002 77003 |
Pediatricians
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
71045 to 71048 |
Podiatrists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
73600 73610 73620 73630 73650 73660 |
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76881 76882 76883*** 76942 |
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*** New 2023 AMA addition, CPT 76883 effective 03/01/2023. No Prior Authorization required.
Pulmonologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
71045 to 71048 |
Radiation Oncologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
76873 77012 77014* 76965 77387 |
* These procedures require prior authorization/pre-service medical necessity review call 1-866-496-6200.
Reproductive Endocrinologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
77063 77067 |
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|
77080** 77081** 77085** 76815 76816 76817 76830 to 76857 74740 76376 76948 |
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76801 76802 76805 76810 76811 76812 76813 76814 76818 76819 76820 76821 76825 76826 76827 76828 76941 76945 76946 93325 |
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** Reimbursement of DEXA studies are subject to both benefit and appropriateness criteria. See all related policies.
Rheumatologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
72020 72040 72050 72052 72070 to 72120 72170 72190 72200 to 72220 73000 to 73140 73501 to 73503 73521 to 73523 73525 73551 73552 73560 73562 73564 73565 73580 73590 73592 73600 73610 73615 73620 73630 73650 73660 76000 76881 76882 76883*** 76942 77002 77073 77077 77080 77081 77085 |
*** New 2023 AMA addition, CPT 76883 effective 03/01/2023. No Prior Authorization required.
Sports Medicine, Physical Medicine and Rehab
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
71100 to 71111 71120 to 71130 72020 72040 72050 72052 72070 to 72120 72170 72190 72200 to 72220 73000 to 73140 73501 to 73503 73521 to 73523 73525 73551 73552 73560 73562 73564 73565 73580 73590 73592 73600 73610 73615 73620 73630 73650 73660 |
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76881 76882 76883*** 76942 |
*** New 2023 AMA addition, CPT 76883 effective 03/01/2023. No Prior Authorization required.
Urologists
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
76775 76857 76870 76872 76873 76942 76965 93980 93981 |
Vascular Surgeons
Procedure Codes | Practitioner Accreditation/Certification Requirement | Laboratory Accreditation/Certification Requirement |
77001 76937 76942 93880 93922 to 93924 |
References:
- American Association of Clinical Endocrinologists (AACE), Endocrine Certification in Neck Ultrasound (ECNU) www.aace.com/college/ECNU/
- American Board of Radiology (ABR) www.theabr.org/
- American College of Cardiology (ACC) www.acc.org/
- American College of Nuclear Medicine (ACNM) www.acnmonline.org/
- American College of Radiology (ACR)www.acr.org/
- American Osteopathic Board of Radiology (AOBR)www.aocr.org/
- American Registry for Diagnostic Medical Sonography (ARDMS) www.ardms.org/
- American Registry of MRI Technologists (ARMRIT) www.armrit.org/index.shtml
- American Registry of Radiologic Technologists (ARRT) https://www.arrt.org/
- American Society of Nuclear Cardiology (ASNC) www.asnc.org/
- American Institute of Ultrasound in Medicine (AIUM) www.aium.org/
- Canadian Association of Medical Radiation Technologists (CAMRT) www.camrt.ca/
- Federal Drug Administration (FDA), Radiation Emitting Products www.fda.gov/Radiation-EmittingProducts/default.htm
- International Society of Bone Densitometry (ISCD) www.iscd.org/
- Intersocietal Accreditation Commission (IAC) www.intersocietal.org/intersocietal.htm
- Intersocietal Commission for the Accreditation of Computed Tomographic Laboratories (ICACTL) http://www.intersocietal.org/ct/
- Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) http://www.intersocietal.org/echo/
- Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories (ICAMRL) http://www.intersocietal.org/mri/
- Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL) http://www.intersocietal.org/nuclear/
- Intersocietal Commission for the Accreditation of Vascular Testing (ICAVL) http://www.intersocietal.org/vascular/
- Mammography Quality Standards Act (MQSA) https:// www.fda.gov/radiation-emitting-products/regulations-mqsa/mammography-quality-standards-act-mqsa