Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging

Reimbursement Policy:
Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging

Effective Date:
02/25/2019

Purpose:
Provide guidelines related to E&M services when billed with a global radiology service, or same day as a stress test, stress echo and myocardial profusion imaging. This policy shall apply to professional providers

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
Horizon BCBSNJ shall deny:

  1. E&M Services (99201-99239, 99281-99444, 99450-99499, G0296, G0396-G0397, G0402, G0436-G0439, G0442-G0447, G0473, G0501, G9156, S0353-S0354, S0280-S0281) when billed with a radiology service and the provider specialty is Radiology.
  2. Low level E&M services (99201-99202, 99211-99212, 99224, 99231) when billed by any provider on the same day as a stress test, stress echocardiography or myocardial perfusion imaging.

In these instances, the E&M services are deemed to be included in the reimbursement for radiology service.

Procedure:
Horizon BCBSNJ shall deny E&M services when billed as part of a global imaging service and the provider is a radiologist, or when billed by any provider on the same day as a stress test, stress echocardiography or myocardial perfusion imaging.

No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply. Providers may not balance bill for difference due to reduced payment.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions::
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
11/26/2018: Policy approved

Policy125_V1.0_11262018