Radiology

The usual fee for therapeutic radiology does not include:

• Consultations regarding the need for radiotherapy    
• Treatment planning    
• Concomitant surgical, diagnostic radiology or laboratory services   

Overreads/Second Interpretations

If more than one of the same X-ray is taken of a location (e.g., because patient moved or film is not clear) only one X-ray is considered payable and the others would be considered content of that service. If more than one physician interprets an X-ray, only one will be paid. BCBSNE does not pay for “overreads.”  

Professional/Technical Components

Professional and technical components together represent a global charge and must not be submitted with either 26 or TC modifiers. Modifier 26 identifies the professional component of a two-component service. Modifier TC identifies the technical component of a two-component service.

When both professional (modifier-26) and technical (modifier-TC) components are included in the charge, representing a global service, the usual fee is considered to include the cost of materials and technical operation costs as well as the professional fee for the administration of diagnostic ultrasound/imaging and other high-energy modalities.    

Date of service for the professional component must be submitted with the same date of service as the technical component even if the professional service is performed on a different date. Both professional and technical components must be billed with the date of service that services were rendered.

Please refer to the Medicare Physician Fee Schedule (PPRVU) for services valid with modifier 26 and modifier TC. Radiology services with a PCTC indicator of “1” represent services that can have both professional and technical components.

Repeated Radiology Procedures on Same Day

If more than one of the same X-ray is taken of a location (e.g., because patient moved or film is not clear) only one X-ray is considered payable, and the others would be considered content of that service. Charges must be billed as separate lines when the same radiology procedure is repeated by the same or different doctor on the same day. Modifiers must be used to indicate a repeat radiology service was performed.

Documentation may be requested by BCBSNE from the provider that supports the use of this modifier. Please review the modifier definition according to CPT coding guidelines to ensure it is being applied correctly.  

Bilateral Radiology Service

Payment for bilateral radiology service is based on Centers for Medicare & Medicaid Services (CMS) bilateral indicators found on the Medicare Physician Fee Schedule (PPRVU). Radiology services reported as bilateral must be submitted with 50 modifier and one unit on one line or RT and LT modifiers with two units. Payment is based on each side. 

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Services

Effective April 1, 2024, BCBSNE will apply a payment reduction when multiple eligible diagnostic imaging services are provided to the same patient on the same day by the same provider or different providers within the same group practice. 

Aligning with CMS, MPPR on certain diagnostic imaging services applies to the professional component and technical component services. It applies to both professional component-only services, technical component-only services, professional component and technical component of global services, and to multiple units of the same technical component and professional component services.

Full payment is made for each professional component and technical component service with the highest payment under the Medicare Physician Fee Schedule for the procedures with a multiple surgery value of ‘4’ in the Medicare Fee Schedule database. Payment is made at 95% for subsequent professional component services. Payment is made at 50% for subsequent technical component services. 

Professional claims with diagnostic imaging services should be submitted with a single date of service on each line.