N.J. Admin. Code § 10:54-4.21

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:54-4.21 - Radiology; diagnostic imaging and ultrasound

(a) Reimbursement for radiological services provided by a physician(s) other than those physicians listed in N.J.A.C. 10:54-4.19 shall be limited to diagnostic radiology of long bones and/or radiological chest examination, in emergency situations to the physician's own patients, in his or her own office.

(b) The fees for routine diagnostic radiology shall include usual contrast media, equipment, materials, consultation, and written reports to the referring physician.

1. For special high risk patients who require the use of low osmolar contrast material to prevent adverse reactions, reimbursement shall be based on the volume of contrast injected, as specified in N.J.A.C. 10:54-9.6, HCPCS.

(c) For diagnostic radiology when combined procedure codes are indicated, specific procedure codes shall not be reimbursed separately when performed in conjunction with other procedure codes and shall be denied if billed together, as follows:

1. Esophagus X-rays shall not be eligible for separate reimbursement when performed in conjunction with a gastrointestinal or small bowel series.

2. Pelvic X-rays shall not be eligible for separate reimbursement when performed in conjunction with complete lumbosacral spine X-rays.

3. Bilateral hip X-rays code (HCPCS 73520) shall be used instead of separate HCPCS codes for each hip (HCPCS 73500 or 73510).

(d) The CPT narrative shall be used to define the permitted number of views to be taken in order to justify the reimbursement for any given radiological procedure.

(e) Reimbursement for radiological services (HCPCS 70000-79999) includes two components, the professional component and the technical component. (See N.J.A.C. 10:54-9.6, HCPCS):

1. The professional component (PC) (see N.J.A.C. 10:54-9) includes the services performed by the physician for Supervision and Interpretation (S & I) of the study, as well as writing the required report. (Use modifier "26" following the CPT code and specify the correct place of service on the claim form.)

2. The technical component (TC) includes the use of the equipment, supplies, routine contrast material, and the technician's time. (Specify the correct place of service on the claim form.)

3. When both the professional and technical components of the service are provided, do not use modifier "TC" or "26" with the HCPCS.

(f) Injection codes related to diagnostic radiologic services should be billed by either the radiologists or other specialists using specific HCPCS codes, as appropriate.

(g) The fee schedule for all radiological services performed in a hospital setting (as indicated in the column in the HCPCS codes) represents the professional component (PC) for those radiologists whose reimbursement is on a fee-for-service basis and not part of hospital costs. In this case, the radiologist shall bill the Medicaid/NJ FamilyCare program directly.

(h) Physician radiological services to both hospital inpatients and outpatients, for which the physician is customarily reimbursed directly by the hospital under contractual or other arrangements, shall be a reimbursable hospital cost and shall be billed by the hospital and not directly to the Medicaid/NJ FamilyCare program by the physician.

(i) No radiological services shall be provided in the outpatient hospital setting without the referral of a physician or other licensed medical practitioner, acting within his or her scope of practice.

N.J. Admin. Code § 10:54-4.21

Recodified from N.J.A.C. 10:54-4.20 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:54-4.21, Radiology; Computerized Tomography (CT), Magnetic Resonance Imaging (MRI) and Ultrasound, recodified to N.J.A.C. 10:54-4.22.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (b)1 and (e) introductory paragraph, amended the N.J.A.C. reference.
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (g) and (h), inserted "the" preceding and "/NJ FamilyCare program" following "Medicaid".