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

Effective Date: October 14, 2019

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

Scope:
Products included:

  • NJ FamilyCare/Medicaid Plan
  • Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Policy:
Horizon NJ Health shall deny:

  1. Evaluation and Management (E&M) Services (CPT Codes 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 (CPT codes 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 NJ Health shall deny Evaluation and Management (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.

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

  • Benefit Limitations
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 13, Radiology Services and Other Diagnostic Procedures cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services