Section 405 IAC 5-27-1 - Reimbursement limitationsAuthority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
(a) Medicaid reimbursement is available to radiology inpatient and outpatient facilities, freestanding clinics, and surgical centers for services provided to recipients subject to the following limitations:(1) Prior authorization is required for any radiological services that exceed the utilization parameters set out in this article.(2) To be eligible for reimbursement, a radiological service must be ordered in writing by a physician or other practitioner authorized to do so under state law.(3) Radiological service facilities must bill Medicaid directly for components provided by the facility. When two (2) practitioners separately provide a portion of the radiology service, each practitioner shall bill Medicaid directly for the component he or she provides. Medicaid will reimburse a physician or other practitioner for radiological services only when such services are performed under the physician's or practitioner's direct supervision.(b) Radiology procedures cannot be fragmented and billed separately. Such procedures may include, but are not limited to, the following:(1) CPT codes for supervision and interpretation procedures will not be reimbursed when the same provider bills for the complete procedure CPT code.(2) If two (2) provider specialties are performing a radiology procedure, the radiologist shall bill for the supervision and interpretation procedure with the second physician billing the appropriate injection, aspiration, or biopsy procedure.(3) Angiography procedures when performed as an integral component of a surgical procedure by the operating physician will not be reimbursed. Such procedures include, but are not limited to, the following:(A) Angiography injection procedures during coronary artery bypass graft.(B) Peripheral percutaneous transabdominal angioplasty procedures.Office ofthe Secretary of Family and Social Services; 405 IAC 5-27-1; filed Jul 25, 1997, 4:00p.m.: 20 IR 3350; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAErrata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACAFiled 9/11/2019, 9:52 a.m.: 20191009-IR-405180375FRAReadopted filed 11/13/2019, 11:54 a.m.: 20191211-IR-405190487RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA