Outpatient Imaging and Radiology Billing Manual

• General Benefit Policies
• Payment for Covered Services/Procedures
• Covered Imaging and Radiology Procedures
• Benefit Limitations
  • Computed Tomography
  • Magnetic Resonance Imaging
  • Preventive Lung Cancer Low Dose Computed Tomography (LDCT) Screening
• Coding Guidelines
  • Unlisted Procedure Codes
  • Billing Modifiers for Bilateral Radiology Procedures
• Prior Authorization Requirements and Information
  • PAR Revisions
  • PAR Exceptions
  • PAR Denials
  • Other PAR Policies
• Billing Information
  • Ordering, Prescribing and Referring (OPR) Providers
  • Billing Edits
• Procedure/HCPCS Codes Overview
• CMS 1500 Paper Claim Reference Table
  • CMS 1500 Radiology Claim Example
• Timely Filing
• Outpatient Imaging and Radiology Revisions Log

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General Benefit Policies

Providers must be enrolled as a Health First Colorado (Colorado's Medicaid program) provider in order to:

• Treat a Health First Colorado member, and
• Submit claims for payment to Health First Colorado.

Imaging and radiology services are a benefit under the following conditions:

1. Services must be authorized and supervised by a licensed physician.
2. The services are performed to diagnose conditions and illnesses with specific symptoms.
3. The services are performed to prevent or treat conditions that are Health First Colorado covered benefits.
4. The services are not routine diagnostic tests performed without apparent relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.
5. Radiology services are performed by a provider with equipment certified by the Colorado Department of Public Health and Environment (CDPHE) and enrolled as a Health First Colorado Provider.

The Department of Health Care Policy & Financing (the Department) periodically modifies billing information. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented.

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Payment for Covered Services/Procedures

Regardless of whether Health First Colorado has actually reimbursed the provider, billing members for covered procedures is strictly prohibited. Balance billing is prohibited. If reimbursement is made, providers must accept this payment as payment in full. Refer to Program Rule 8.012. The provider may only bill the member for procedures not covered by Health First Colorado.

• Members may be billed for non-covered procedures in accordance with C.R.S. 25.5-4-301(1)(a)(I).
  • (1) (a) (I) Except as provided in section 25.5-4-302 and subparagraph (III) of this paragraph (a), no recipient or estate of the recipient shall be liable for the cost or the cost remaining after payment by Medicaid, Medicare, or a private insurer of medical benefits authorized by Title XIX of the social security act, by this title, or by rules promulgated by the state board, which benefits are rendered to the recipient by a provider of medical services authorized to render such service in the state of Colorado, except those contributions required pursuant to section 25.5-4-209 (1). However, a recipient may enter into a documented agreement with a provider under which the recipient agrees to pay for items or services that are nonreimbursable under the medical assistance program. Under these circumstances, a recipient is liable for the cost of such services and items.
• If a PAR for procedures are required, the following policy applies:
  • Technical/lack of information (LOI) denial does not mean those procedures are not covered. Members may not be billed for procedures denied for LOI.
  • Procedures partially approved are still considered covered procedures. Members may not be billed for the denied portion of the request.
  • Procedures totally denied for not meeting medical necessity criteria are considered non-covered services.

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Covered Imaging and Radiology Procedures

Health First Colorado covers procedures including but not limited to: angiograms, computed tomography (CT scans), electrocardiograms (ECG), magnetic resonance imaging (MRI scans), mammograms, positron emission tomography (PET scans), radiation treatment, ultrasounds, and X-rays.

An exhaustive list of covered procedures may be found on the Department's Fee Schedule located on the Provider Rates and Fee Schedule web page.

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Benefit Limitations

1. Procedures for cosmetic treatment or infertility treatment (ICD-10 N97) are not covered.
2. Procedures considered experimental or not approved by the Food and Drug Administration (FDA) are not covered.
3. Procedures not ordered by the member's attending or treating physician are not covered.
4. Procedures which are part of a clinical study are not covered.

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Computed Tomography

1. CT of sinuses for acute, uncomplicated rhinosinusitis (ICD-10 J01) is not covered.
2. Virtual Colonoscopy (CPTs 74261, 74262, 75263) is covered at a frequency of once every five years.

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Magnetic Resonance Imaging

1. Imaging of cortical bone and calcifications, and procedures involving spatial resolution of bone and calcifications are not covered.
2. Imaging of the same anatomic area to address patient positional changes, additional sequences, or equipment failure is not allowed. These variations or extra sequences are included within the original imaging authorization request.

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Preventive Lung Cancer Low Dose Computed Tomography (LDCT) Screening

Health First Colorado covers annual screening for lung cancer in accordance with the U.S. Preventive Services Task Force (USPSTF) recommendation.

The following policies are effective as of January 1, 2021:

HCPCS code G0297 has been replaced with CPT code 71271.

1. CPT code 71271 must be used and always requires Prior Authorization.
2. ICD-10 diagnosis code Z12.2 must be reported on the claim.
3. Benefit is limited to one screening (one billed unit of service) per state fiscal year (July 1 - June 30).

The following policies were effective prior to January 1, 2021:

1. HCPCS code G0297 must be used. G0297 always requires Prior Authorization.
2. ICD-10 diagnosis code Z12.2 must be reported on the claim.
3. Benefit is limited to one screening (one billed unit of service) per state fiscal year (July 1 - June 30).

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Coding Guidelines

1. Regardless of billing provider type, component modifiers must be indicated on the claim if reimbursement for the procedure is split between the professional and technical components.
   1. Professional component - modifier 26
   2. Technical component - modifier TC
2. Claims lacking a component modifier are understood to be inclusive of both components and will be reimbursed as payment in full for the entire procedure. Any separate claim for the same procedure, billed on the same date of service, will be considered an overpayment and may be subject to recovery.
3. Outpatient Hospital claims for Imaging and Radiology must be billed via an 837I (UB-04 paper claim), Practitioner procedure claims must be billed via an 837P (CMS1500 paper claim)
4. National Correct Coding Initiative (NCCI) billing edits affect this benefit. Providers should be familiar with the information on the National Correct Coding Initiative in Medicaid web page on the Centers for Medicare & Medicaid Services (CMS) website, including the NCCI Policy Manual found there.
5. All claims must include the National Provider Identification (NPI) number of the enrolled provider who rendered the service.
6. All claims must include the NPI number of the enrolled provider who ordered the service.

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Unlisted Procedure Codes

Unlisted radiology procedure codes are used when there is no CPT or HCPCS code that accurately identifies the services performed. Unlisted procedure codes will be priced by a clinical reviewer with the Department's fiscal agent.

Claims with unlisted codes must include as attachments the operating report from the procedure and the Unlisted Procedure Code Form located on the Provider Forms web page under the Claim Forms and Attachments drop-down. All lines on the Unlisted Procedure Code Form must be completed. The Department will deny claims lacking the required attachments. Claims denied for incomplete information will have to be resubmitted with the correct information for reimbursement.

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Billing Modifiers for Bilateral Radiology Procedures

Bilateral radiology procedures should be reported using modifiers RT and LT. When using both modifiers for an appropriate radiology code on the same claim, each code should be billed on a separate line of the claim: one (1) with modifier RT indicating the right side, and one (1) with modifier LT indicating the left side. If bilateral radiology procedures are reported using modifier 50, claims may be denied.

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Prior Authorization Requirements and Information

Health First Colorado requires all outpatient hospitals and free-standing radiology/X-ray facility centers to obtain a prior authorization (prior authorization request, PAR) for most non-emergent CT, non-emergent MRI, and all PET scans. A PAR precedes the submission of a claim and must be approved in advance of the claim. Procedures which require a PAR cannot be claimed for without an approved PAR on record. Refer to the Department's Fee Schedule located on the Provider Rates and Fee Schedule web page for a list of all procedure codes which require a PAR.

All Imaging and Radiology PARs and revisions are processed by the ColoradoPAR Program and must be submitted using Atrezzo, the Acentra portal. PARs submitted via fax or mail will not be processed. These PARs will be returned to providers via mail. This requirement only impacts PARs submitted to the ColoradoPAR Program.

To ensure claims are quickly and accurately processed, all claims for procedures which require a PAR must:

• Contain the correct Billing Provider ID number.
• Contain procedure codes which match the corresponding PAR on record.
• Contain modifier codes which match the corresponding PAR on record.

Contact the ColoradoPAR Program or visit the Department's ColoradoPAR Program web page for more information.

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PAR Revisions

If a procedure is prior authorized but the desired test was changed just prior to the time of the service, the provider is responsible for submitting a PAR revision with adequate documentation within 48 hours of the date of service for the PAR to be processed by the ColoradoPAR Program. PAR revisions can only be submitted using Atrezzo. Contact the ColoradoPAR Program with questions regarding how to process PAR revisions.

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PAR Exceptions

To request a PAR exception, contact the ColoradoPAR Program or visit the Department's ColoradoPAR Program web page.

1. Emergency outpatient imaging and radiology procedures are exempt from PAR requirements. To mark a claim as emergency, check the emergency indicator field.
2. All PET and SPECT scan procedures require prior authorization regardless of whether emergency is indicated.
3. A PAR is not required when Medicare, Medicare Advantage plans, or private insurance has made primary payment on the claim. If third party liability (TPL) carriers have not made payment on the claim, the service must be prior authorized to ensure it meets medical necessity standards of the Health First Colorado program.
4. PARs are not required of any Imaging and Radiology procedure for the professional component if the procedure billing is split between components. The technical component still requires prior authorization.

The Department will allow retroactive authorizations when a member's eligibility is determined after the date that the service is performed. When a member's eligibility is determined after the date of service, the member is issued a Load Letter. The Load Letter must be submitted with the supporting clinical documentation for the PAR for a retroactive request to be processed by ColoradoPAR.

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PAR Denials

If the PAR is denied, contact the ColoradoPAR Program or visit the Department's ColoradoPAR Program web page.

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Other PAR Policies

• It is the provider's responsibility to maintain clinical documentation to support procedures provided in the member's file in the event of an audit or retroactive review. Submitted PARs without minimally required information or with missing or inadequate clinical information will result in a lack of information (LOI) denial.
• All accepted PARs are reviewed by the authorizing agency. The authorizing agency approves or denies, by individual line item, each requested service or supply listed on the PAR.
• Paper PAR forms and completion instructions are located on the Provider Forms web page. They must be completed and signed by the member's physician and submitted to the authorizing agency for approval.
• Providers should not render procedures or submit claims for procedures that require prior authorization before the PAR is approved. After the authorizing agency has reviewed the request, the PAR status is transmitted to the fiscal agent's prior approval system.
• The status of the requested procedures is available through the Provider Web Portal. In addition, after a PAR has been reviewed, both the provider and the member receive a PAR response letter detailing the status of the requested procedures. Some procedures may be approved and others denied. Check the PAR response carefully as some line items may be approved and others denied.
• Approval of a PAR does not guarantee Health First Colorado reimbursement and does not serve as a timely filing waiver. Authorization only assures that the approved service is a medical necessity and is considered a Health First Colorado covered benefit.

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Billing Information

Ordering, Prescribing and Referring (OPR) Providers 

Health First Colorado complies with Federal Medicaid Regulations in 42 CFR 455.410(b) which provide that Medicaid must require all ordering or referring physicians or other professionals providing services be enrolled as providers, and 42 CFR 455.440, which provides that Medicaid must require all claims for the payment of items and services that were ordered, referred, and prescribed to include the National Provider Identifier (NPI) of the ordering, referring or prescribing physician or other professional.

Effective July 1, 2022, the Department will enforce the federal requirement 42 CFR § 455.440 that claims for all Imaging and Radiology services, rendered by any type of provider, contain the NPI of the provider who ordered the services, and that the NPI is actively enrolled with Health First Colorado. The ordering NPI may be that of the qualified provider overseeing the member’s care, for example as is the case with maternity services.   

Providers are instructed to place the NPI of the ordering provider into the following locations for claim submission: 

Professional Claims

• Paper claims use field 17.b
• Electronic submissions use loop 2420e with qualifier DK.

Imaging and Radiology services can be ordered by either a physician, physician assistant, or advanced practice nurse. The ordering provider must also be actively enrolled with Health First Colorado. If these conditions are not met the claim will be denied. 
Visit the OPR Claim Identifier Project web page for further information on this project.

Refer to the General Provider Information Manual located on the Billing Manuals web page for general billing information.

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Billing Edits

The provider's adherence to the application of policies in this manual is monitored through either post-payment review of claims by the Department, or computer audits or edits of claims. When computer audits or edits fail to function properly, the application of policies in this manual remain in effect. Therefore, all claims shall be subject to review by the Department.

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Procedure/HCPCS Codes Overview

All outpatient radiology procedures must be billed using HCPCS codes.

When submitting claims for radiology to the Health First Colorado, observe the following guidelines:

• Always use the most current CPT revision. The Health First Colorado adds and deletes codes as they are published in annual revisions of the CPT.
• Use CMS codes only when CPT codes are not available or are not as specific as the CMS codes.

Not all codes listed in the annual Health First Colorado HCPCS code publications are benefits of the Health First Colorado. Read the entire entry to determine the benefit status of the item.

The CPT Manual can be purchased at local university bookstores and from the American Medical Association at the following address:

Book & Pamphlet Fulfillment: OP 341/9
American Medical Association
P.O. Box 10946
Chicago, Illinois 60610

Refer to the General Provider Information Manual for more information on the procedure/HCPCS codes.

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

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CMS 1500 Radiology Claim Example

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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Outpatient Imaging and Radiology Revisions Log