DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

This policy provides information regarding the coverage of medical benefits, as determined by applicable federal and/or state legislation.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Human Services (DHS) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for Multiple Imaging Reduction.

Definitions

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT).

Multiple Procedure Indicator (MPI)- Indicator to show which payment adjustment rule for multiple procedures will apply to the service.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

When there is more than one diagnostic imaging procedure performed in one session for the same member on the same date of service by the same provider, there is a reduction in the reimbursement for secondary sub-services, for both technical component and professional services. 

Multiple Diagnostic Imaging Reductions (MDIR) will apply when Multiple diagnostic imaging procedures are performed on the same patient by the Same Group Physician and/or Other Health Care Professional during the Same Session. 

When Multiple Diagnostic Imaging Reductions (MDIR) will not apply: 

·       When/if the diagnostic imaging procedure is the primary procedure as ranked based on the RVU assigned to the code and modifier, compared to other diagnostic imaging procedures billed during the same session.

·       When multiple diagnostic imaging procedures are billed, it may be appropriate to append modifier 59 or XE to indicate that the procedure was performed on the same day/encounter by the same provider.

·       When multiple diagnostic imaging procedures are billed for the same patient on same day but not by same group physician during same session 

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is

subject to audit by Highmark Health Options at any time pursuant to the terms of your provider

agreement.

CMS requires that documentation supports medical necessity of repeating the procedure.

To designate professional component modifier 26, the provider must prepare a written report that includes findings, relevant clinical issues, and if appropriate comparative data. (Must be available upon request)