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Laboratory/Pathology Services

PrimeWest Health covers all laboratory tests paid under the Clinical Laboratory Improvement Amendment (CLIA) Certificate Fee Schedule from the Centers for Medicare & Medicaid Services (CMS).

To be eligible for PrimeWest Health payment as a laboratory/pathology service, the service must be all of the following:

1. Ordered and provided by or under the direction of a member’s treating physician (Medical Doctor [MD], Doctor of Optometry [OD], Doctor of Podiatric Medicine [DPM], or Doctor of Dental Surgery [DDS]) or practitioner (nurse practitioner, clinical nurse specialist, physician assistant, or certified professional midwife) who gives a consultation or treats a member for a specific medical problem within his/her scope of practice as defined by State law
2. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) products/services and laboratory and X-ray services payable under Medicare Part B ordered or referred by an optometrist
3. Provided in a hospital or independent laboratory
4. Directly related to the diagnosis and treatment of a member’s health status
5. Authorized under the laboratory’s CLIA certification

PrimeWest Health follows Medicare guidelines. All hospitals and physician owned and freestanding laboratories require CLIA certification. Claims will be denied for lab services provided by laboratories without CLIA certification or if the CLIA certification number is not on file with PrimeWest Health.

Eligible Providers

To be eligible as a provider of laboratory services, a vendor must be certified under CMS’ CLIA program.

Providers of lab services must have their CLIA certificate number current and up-to-date with their most recent level of certification on file with PrimeWest Health. If you did not indicate your certificate number on your PrimeWest Health enrollment application, or your office has obtained a certificate since your original enrollment, please provide PrimeWest Health Provider Enrollment with the following information:

1. Provider name
2. Provider National Provider Identifier (NPI) number
3. CLIA certificate number
4. CLIA certificate expiration date

Send or fax this information to:

PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Fax: 1-320-762-8750

Outpatient Hospital Laboratory Tests

Effective for dates of service (DOS) on or after January 1, 2014, PrimeWest Health follows Medicare hospital outpatient clinical laboratory test payment and billing policy, except where services under arrangement and referred lab services are concerned. Most clinical diagnostic laboratory tests (excluding molecular pathology tests) performed in an outpatient hospital setting are packaged under the Outpatient Prospective Payment System (OPPS), instead of the Clinical Laboratory Fee Schedule (CLFS).

Refer to CMS Manual System Pub 100-04, Medicare Claims Processing, Medicare Claims Processing, for additional information.

Technical Component of Surgical Pathology

The technical component of surgical pathology and supplies is not subject to CLIA requirements. When providing only these services, do not apply for CLIA certification. Billing for the technical component of a lab test includes the following:

1. The slide preparation for interpretation by the physician
2. Other usual pre-slide preparation

Automated Multichannel Laboratory Organ or Disease Oriented Panels

The organ and disease panel codes represent chemistry tests that are frequently performed in combination on automated multichannel equipment. When combinations of these tests are provided for a member on the same date, claims submitted to PrimeWest Health are subject to a payment cap specified by CMS for the Medicare program.

All multichannel laboratory tests performed on the same member on the same date must be submitted on one claim. Billing the complete automated chemistry panel is advisable, if all tests are done. Additional tests for the same date and same member submitted on a separate claim are considered part of the panel and will be denied as a duplicate test. 

If subsequent tests are provided for the same patient on the same date, submit a replacement claim and include the additional tests on one claim transaction. 

The Physician’s Current Procedural Terminology (CPT) Manual defines the organ and disease-oriented panel codes. If other tests are performed in addition to those indicated for a particular panel, report the tests on individual lines on the claim along with the CPT panel codes. 

Do not separately report individual laboratory tests that are components of multichannel test analysis. 

PrimeWest Health will process Medicare crossover claims as submitted per Medicare’s billing instructions in the CMS Medicare Claims Processing Manual.

Handling/Specimen Collection

PrimeWest Health does not reimburse for collection of blood by access port in conjunction with another service. These services are incidental and included in the primary service.

PrimeWest Health will cover the collection and handling (if applicable) for each type of specimen listed below, per member, per day:

1. Routine venipuncture for collection of specimens
2. Catheterization for collection of a specimen, single patient, homebound/nursing facilities (NFs)
3. Catheterization for collection of a specimen, multiple members

Minnesota Department of Health (MDH) Newborn Screening Program

PrimeWest Health will reimburse for the MDH newborn screening for metabolic disorder card in the diagnosis-related group (DRG) or facility fee only when provided in an inpatient or birthing center setting. Do no bill separately from the facility fee.

PrimeWest Health will cover the cost of the newborn screening metabolic disorder card when screening cannot be completed at the inpatient hospital or birthing center setting with HCPS code S3620. If a repeat newborn screening card is requested, bill S3620 with modifier 76 or 77.

Laboratory Services

PrimeWest Health requires all physician office laboratories to be CLIA-certified in order to receive payment. CLIA regulations include the conditions that all laboratories must meet to be certified to perform testing on human specimens under CLIA. Claims will be denied for physician office laboratories that do not meet CLIA requirements, either because the laboratory’s CLIA certificate has expired, the billed test is not covered by the laboratory’s CLIA certificate, or the services rendered are outside the effective dates of the CLIA certificate.

Payment for a laboratory service performed in a CLIA-certified physician’s laboratory will not exceed the amount paid for similar services performed in an independent laboratory. Physicians may also send laboratory specimens to independent or outpatient hospital laboratories.

Reference and Outside Lab Services

Effective for dates of service on and after January 1, 2015, in conjunction with Section 1902(a)(32) of the Social Security Act, PrimeWest Health must only reimburse a provider who personally performed a service. PrimeWest Health will no longer pay a provider for laboratory services that the provider sent to a reference or outside laboratory except in cases where an outpatient hospital or provider-based clinic where the reference or outside lab service is operating under an arrangement that is within the scope of the hospital’s certification.

Inpatient hospitals and nursing facilities

This policy does not apply to services included in a hospital diagnosis-related group (DRG) payment or nursing facility per-diem payment. Payments for services included in these types of all-inclusive payments are paid to the facility. The reference or outside laboratory may not bill separately in these situations.

Minnesota Family Planning Program (MFPP) lab tests and services

Refer to the Lab Services section when billing lab tests.

MFPP-certified physicians treating members that have presumptive eligibility (PE) for MFPP may bill for lab tests or services when the following are true:

1. The tests or services are performed at your facility
2. The tests or services are performed on the same day as other family planning services
3. The primary diagnosis is in the Z30 – Z30.9 range

If you send lab tests to a reference or independent lab provider, refer to the Reference and Outside Lab Services policy in the Lab Services section. Give the lab provider the following information so the lab can bill for the service:

1. A copy of the member’s MFPP Short-Term Approval Notice (gives the lab provider at least two of three recipient identifiers [first and last name, date of birth, SSN] so the lab can verify eligibility on EVS or MN–ITS)
2. Primary diagnosis code in the Z30 – Z30.9 range
3. Secondary diagnosis codes as appropriate
4. The primary ordering provider’s NPI

If an MFPP member does not have an MHCP ID number, do the following:

1. Perform the lab tests
2. Wait 3 business days
3. Use the information from the MFPP provider to obtain the member’s PrimeWest Health ID number
4. Bill PrimeWest Health for the lab tests performed using the primary diagnosis code in the Z30 – Z30.9 range sent from the referring/ordering provider

All PrimeWest Health-enrolled labs are required to perform lab tests ordered for members during the PE period and after a member’s MFPP ID number is determined and available on EVS or MN–ITS (usually 3 business days after the physician determines PE).

Billing in Units

Bill laboratory tests that are not repeats in units. Do not use the repeat modifier. For example, bill blood, urine, and other cultures in “units of.” Multiple organism identifications (IDs) should also be billed in “units of.”

Pap Smear Billing

PrimeWest Health covers one professional and one technical component for Pap smear testing, per specimen per day. 

Cytogenetic Testing

Documentation in the medical record must reflect the medical necessity for the testing. All claims submitted for payment of cytogenetic testing must contain the specific diagnosis related to the tests being performed. Use the most specific International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM) code available. (Some cytogenetic tests require authorization; for example: chromosome analysis.) Bill cytogenetic testing in units.

PrimeWest Health does not cover cytogenetic testing for the following:

1. Legal, paternity, or informational purposes, unless it is medically necessary for the member to receive cytogenetic testing
2. Family members who are not PrimeWest Health members
3. Fetus testing

Genetic Testing

All genetic testing requires a Service Authorization before it is performed.

PrimeWest Health requires a written physician order for the following genetic analysis procedure codes: 81225, 81226, 81227, 81240, 81241, 81291, and 81355. The molecular pathology/gene analysis tests must be ordered by a physician or qualified practitioner when it is medically necessary for the diagnosis or treatment of the member. Tests not ordered by the physician who is treating the member are not considered reasonable and necessary.

Genetic testing is considered medically necessary when all of the following conditions are met and documented in the medical record:

1. The member displays clinical features or is at direct risk of inheriting the genetic condition in question (pre-symptomatic)
2. The result of the test will have a clinically significant effect on the treatment being delivered for a disease or syndrome
3. The testing method is considered scientifically valid for the identification of a specific genetically linked inheritable disease
4. Appropriate genetic counseling occurs before and after testing. Counseling documentation supports the intent to change therapy based on the results of the testing.

Genetic testing is not covered when performed in the absence of symptoms or high-risk factors for an inheritable disease or when knowledge of genetic status will not affect treatment decisions. Genetic testing for conditions that are treated symptomatically are not appropriate since the treatment would not change based on the test results.

Pharmacogenetic testing is covered when all of the following conditions are met:

1. Testing is required by the drug label
2. The test will change the treatment course
3. A drug trial is considered impractical due to safety or other factors prior to genetic testing

Pharmacogenetic panel tests for therapy selection, such as panel tests for psychotropics, analgesics, or Attention-Deficit/Hyperactivity Disorder (ADHD) stimulant medication, are not covered.

PrimeWest Health covers genetic mutation testing for breast and cervical cancer susceptibility when certain criteria are met. 

Rapid Whole Genome Sequencing

Rapid whole genome sequencing is a genetic test medically indicated for all of the following criteria:

• Critically ill infant or child in the intensive care unit (ICU) with no unifying diagnosis.
• Clinical circumstances present the need for rapid testing in time-sensitive cases as a last resort to guide clinical decision making in treatment or management of patient’s genetic condition. Test must be ordered by the infant’s treating physician and prior to ordering testing, infant must be evaluated by a medical geneticist or other physician subspecialist with expertise in the conditions or genetic disorder for which the testing is being considered, AND one of the following is met:
  • Critically ill infant or child with a history of multiple hospitalizations or readmissions within 30 days of discharge for an unexplained condition which no diagnosis has been reached despite extensive workup and previous testing in the identification of rare genetic disease variant; OR
  • Clinical presentation does not fit a well-defined gene analysis test that is available or previous extensive workup and testing has failed to receive a diagnosis

Oncotype Dx Testing for Breast Cancer

Oncotype Dx testing is a 21-gene assay test, which aims to help breast cancer patients and their physicians determine whether adjuvant chemotherapy would be beneficial. Testing is considered medically indicated for members with all of the following breast cancer characteristics:

1. Stage I or II breast cancer
2. Breast tumor is estrogen-receptor positive
3. Breast tumor is HER2-receptor negative
4. Tumor size 0.6 – 1 cm with moderate/poor differentiation or unfavorable features, or tumor size is greater than 1 cm
5. Negative lymph nodes (nodes with micrometastases less than 2 mm in size)
6. Test result will be used to guide decision making about adjuvant chemotherapy

Home Monitoring of Anticoagulant Therapy

Home use of Prothrombin Time (PT) testing and International Normalization Ratio (INR) monitoring may be covered for members taking oral anticoagulation and with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism if all the following medical indications are present and are prescribed by the treating physician. Home monitoring supplies must also be ordered by the treating physician.

1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device;
2. The patient must receive face-to-face education from the treating provider on anticoagulation management and must demonstrate the correct use of the device prior to its use in the home;
3. The patient must continue to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring;
4. Self-testing with the device should not occur more frequently than once a week.

Lead Toxicity Testing

The lead toxicity screening test consists of a capillary or venous blood lead test, hemoglobin (Hgb), hematocrit (HCT), and other age-appropriate exams or tests (as noted in the schedule of age-related screening standards). Refer to Child and Teen Checkups (C&TC)/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program for more information pertaining to lead toxicity testing.

The following lead testing services are not covered:

1. Paint chip, water, and soil testing
2. Assessments performed by a registered environmental health specialist/sanitarian

Laboratory Testing for HIV Tropism (Trofile)

HIV Tropism testing is considered medically necessary for selecting patients for treatment with HIV co-receptor antagonists.

Tropism testing is covered for patients who meet all of the following criteria:

1. Antiretroviral treatments have failed
2. There is evidence of viral replication
3. There is a diagnosis of HIV

Report HIV Tropism testing using CPT code 87999 with a description of HIV Tropism. Limit of once per lifetime.

Drug Testing

Drug screening for routine work-related issues and when court ordered is not covered. For services other than medication assisted therapy, drug testing costs are not included in the rate.

PrimeWest Health accepts Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes, as follows:

• Screening/presumptive tests: 80305 – 80307 (CPT)
• Definitive drug testing: G0480 – G0483 and G0659 (HCPCS)

If sample validation tests are completed, include or bundle them with CPT Screening drug test codes 80305 – 80307 and in the HCPCS Definitive drug testing codes G0480 – G0483 and G0659.

Drug screening/presumptive tests and definitive drug testing should be individualized to the treatment plan and should not exceed one presumptive/screening drug test every seven days at any time during treatment and one confirmatory/definitive drug test at any time during treatment. Medical documentation should include how the test results influence treatment and level of care decisions. 

Drug or drug classes for which screening is performed should only reflect those likely to be present based on the member’s medical history or current clinical presentation. An appropriately licensed health care professional must order the urine drug testing (UDT). The ordering health care professional must sign and date the order and must specify all drugs and drug classes to be tested and include the clinical indication or medical necessity for the drug test.

Standing orders or orders to “conduct additional testing as needed” are not sufficiently detailed to verify medical necessity.

If the provider of the drug testing is different than the ordering or referring clinician, that provider must maintain hard copy documentation of the lab results along with copies of the order for the drug test. Copies of test results alone without documentation of the treating clinician’s request are not sufficient to support the drug testing services. The frequency of drug testing should be individualized to the treatment plan and should not exceed one every seven days at any time during the treatment.

UDT after the identification of the member’s drugs or use or abuse profile must be limited to the specific drugs present on the initial profile.
 

The member’s medical record must include an appropriate number of UDTs billed over time based on the stage of screening, treatment, or recovery; the rationale for the drugs or drug classes ordered; and the results must be documented in the medical record and used to direct care.
 

The testing frequency for presumptive UDT for members with SUD must meet medical necessity and be documented in the clinician’s medical record.

• For patients with 0 to 30 consecutive days of abstinence, presumptive UDT is expected at a frequency of one to three presumptive UDTs per week. More than three presumptive UDTs in one week are not medically necessary and are not covered.
• For patients with 31 to 90 consecutive days of abstinence, presumptive UDT is expected at a frequency of one to three presumptive UDTs per week. More than three presumptive UDTs in one week are not medically necessary and are not covered.
• For patients with > 90 consecutive days of abstinence, presumptive UDT is expected at a frequency of one to three UDTs in one month. More than three physician-directed UDTs in one month are not medically necessary.

Definitive UDT may be considered medically necessary under the following conditions:

1. A screen results in a negative finding that is inconsistent with the patient’s medical history, current clinical condition or the patient’s own statement
2. Presumptive testing is positive
3. Providers must document exceptions with the rationale for the confirmation testing order in the medical record

Routine confirmations of drug screens with negative results are not deemed medically necessary and are not covered.

Clinical Laboratory Improvement Amendment (CLIA)

Congress passed CLIA in 1988, establishing a minimum quality of standards for all laboratory testing to ensure high quality of testing regardless of the laboratory location.

PrimeWest Health follows Medicare guidelines. All hospitals and physician owned and freestanding laboratories require CLIA certification. PrimeWest Health will not cover lab services provided by laboratories without CLIA certification.

CMS CLIA Requirements

CMS requires all providers performing laboratory testing to register with the CLIA program. Direct inquiries about CLIA certification to CMS.

Use the CMS website as a means to obtain current information about CLIA certification as CMS updates its site on a regular basis. CLIA waiver tests, PPMPs, and tests required under CLIA edit are subject to change at any time. Refer to the CMS web page How to Apply for a CLIA Certificate, which also includes the CMS Clinical Laboratory Improvement Amendments (CLIA) Application for Certification and instructions.

Provider-Performed Microscopy Procedures (PPMP)

PPMP laboratories must meet only the following requirements under CLIA:

1. Enroll in the CLIA program
2. Pay applicable certificate fees biennially
3. Certain quality and administrative requirements

Laboratories with a PPMP certification and those granted CLIA waiver status may perform PPMP tests. Certified PPMP-approved procedures are subject to change at any time.

CLIA Waiver Tests

Waived laboratories must meet only the following requirements under CLIA:

1. Enroll in the CLIA program
2. Pay applicable certificate fees biennially
3. Follow manufacturer’s test instructions

Laboratories with waiver certification (certification type 2) are approved to bill only for waiver tests.

To bill CLIA waiver tests, the procedure code must have the modifier QW. Do not use the CLIA number on the claim form.

All types of certification are effective for two years and include a Certificate of Provider-Performed Microscopy Procedures (PPMP). PPMP certificates are issued to a laboratory in which a physician, midlevel practitioner, or dentist performs specific microscopy procedures. It allows a laboratory to conduct tests categorized as moderately complex. This certificate also permits the laboratory to perform waived tests.

Certificate of Waiver

1. Issued to laboratories that perform only tests the Food and Drug Administration (FDA) or the Centers for Disease Control and Prevention (CDC) have determined are waived tests.
2. Allows the laboratory to conduct tests so simple that there is little risk of error.
3. Laboratories must follow the manufacturer’s instruction for test performance.

Certification of Registration

1. Issued to allow laboratories to conduct tests until they are surveyed and determined to be compliant with the CLIA regulations.
2. Allows the laboratory to conduct tests categorized as moderately and/or highly complex tests.
3. Only laboratories applying for a Certificate of Compliance or a Certificate of Accreditation will receive a Certificate of Registration.

Certification of Compliance

1. Issued after an on-site survey finds that the laboratory is in compliance with all applicable CLIA requirements.
2. Allows the laboratory to conduct tests categorized as moderately and/or highly complex tests. 

Radiology/Diagnostic Services

Eligible Providers

To be eligible as a provider of independent X-ray services or portable X-ray services, a vendor must be certified by CMS for participation in the Medicare program.

Advanced Diagnostic Imaging Providers

To be eligible as a provider of the technical component (TC) of advanced diagnostic imaging (ADI) services for DOS on or after August 1, 2013, providers must be accredited through one of the organizations below. The accreditation requirements apply only to providers of the TC of the imaging service and not the physician’s interpretation (professional component) of the imaging service. The accreditation requirements apply to all suppliers of the TC who submit claims to PrimeWest Health. They do not apply to ADI services done in the hospital (inpatient or outpatient) or ambulatory surgical center settings licensed by Minnesota Statutes.

Providers must be accredited for the modality, CPT, or HCPCS imaging service for which they are billing or their claim will be denied. ADI services include the following:

1. Magnetic resonance imaging (MRI)
2. Computed tomography (CT)
3. Nuclear medicine imaging including positive emission tomography (PET)

The following are the accrediting organizations:

1. The American College of Radiology
2. The Intersocietal Accreditation Commission
3. The Joint Commission
4. RadSite

The billing entity or organization must do the following:

1. Complete and sign an Advanced Diagnostic Imaging Accreditation Requirements – Assurance Statement (DHS-3872)
2. Attach a copy of the organization’s most current accreditation certificate(s)
3. Fax both documents to Minnesota Health Care Programs (MHCP) Provider Enrollment at 1-651-431-7462 upon receipt of accreditation

Each of the accredited organizations will notify providers when it is time to renew accreditation. Providers must submit a new copy of their recertification with a new Advanced Diagnostic Imaging Accreditation Requirements – Assurance Statement (DHS-3872) to MHCP Provider Enrollment. PrimeWest Health will track and verify the accreditation status of providers through DHS enrollment files.

Covered Services

To be eligible for PrimeWest Health payment for radiology or diagnostic services, the service must meet all of the following criteria:

1. Be ordered and provided by or under the direction of a member’s treating physician or practitioner, within the scope of practice as defined by State law. The physician or practitioner must provide a consultation or treat a member for a specific medical problem
2. Results must be used by the treating physician or practitioner in screening, diagnosis or management of a member’s specific health problem
3. Meet CMS or DHS coverage criteria

Professional Component

The professional component of a radiology procedure includes the professional services of the physician and the following:

1. Examination of patient when indicated
2. Performance or supervision of the procedure
3. Interpretation
4. Written report of the examination

The professional component is applicable in an encounter when the physician submits a charge for professional services only. It does not include the cost of personnel, materials, space, equipment, or other facilities.

Technical Component

The technical component of a radiology procedure code includes the personnel and materials, including the following:

1. Contrast media and drugs
2. Film or xerography
3. Space
4. Equipment
5. Other facilities

Oral and/or rectal contrast administration alone does not qualify as a study “with contrast.”

Total Components

Total components include both technical and professional components and are covered by PrimeWest Health. Do not use modifiers when billing for the total components.

Mammography

PrimeWest Health covers medically necessary mammography services.

For Medicaid members, PrimeWest Health will cover a screening mammogram for women at age 40, and annually after age 40. (For billing purposes, “annually” is defined as 335 rolling days from when the member’s previous mammogram was performed.)

Authorization is required for a mammogram before age 40 (includes screening and diagnostic mammograms).

For Medicare members, PrimeWest Health will cover one screening mammogram between the ages of 35 and 39, and annually after age 40. (For billing purposes, “annually” is defined as 335 rolling days from when the member’s previous mammogram was performed.)

Authorization is required before age 35 and for more than one mammogram between ages 35 and 39. The authorization requirement is for both screening and diagnostic mammograms.

All facilities (hospital, outpatient department, clinic, radiology practice, mobile unit, physician’s office, or other facility) providing diagnostic and screening mammography services are required to have Food and Drug Administration (FDA) certification under the Mammography Quality Standards Act (MQSA). No facility may conduct an examination or procedure involving mammography unless the facility has obtained an MQSA certificate.

PrimeWest Health covers HCPCS code G0279 for Digital Breast Tomosynthesis (3-D Mammogram). G0279 is only covered when billed in conjunction with either 77065 or 77066. Report CPT code 77063 for bilateral screening digital breast tomosynthesis (DBT) performed in addition to a primary procedure.

Colonoscopy

PrimeWest Health has adopted preventive and chronic disease practice guidelines appropriate for children, adolescents, prenatal care, young adults, and adult populations. Review the U.S. Preventive Services Task Force Guidelines for Colorectal Cancer Screening.

A screening or diagnostic colonoscopy for members ages 18 – 44 requires Service Authorization.

Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)

PrimeWest Health covers medically necessary MRIs, CT scans, bone density studies, MRIs for angiography, magnetic resonance spectroscopy (MRS), positron emission tomography (PET), and brain mapping. PrimeWest Health will periodically perform audits of claims paid for this service. In the event it is determined medical necessity for the imaging was not met, PrimeWest Health will re-adjudicate the claim. If a facility continues to perform imaging services and medical necessity is not met, that facility will be required to obtain a Service Authorization prior to performing this service.

Service Authorization

PrimeWest Health requires Service Authorization for the following imaging diagnostic tests.

Gastrointestinal Tract Imaging (e.g., Capsule Endoscopy)

PrimeWest Health requires authorization prior to performing intraluminal gastrointestinal tract imaging (91110, 91111).

Breast Magnetic Resonance Imaging (MRI)

A Service Authorization is needed before performing a breast MRI (77046, 77047, 77048, 77049). Scans that use intravenous magnetic resonance (MR) contrast agents and specialized breast coils must be used in all cases.

For MRI of the breast for screening purposes, provide the following information with the authorization request:

1. Age
2. Previous diagnosis of breast cancer, including carcinoma in situ
3. Presence of mutation in BRCA1 or BRCA2
4. Presence of another genetic syndrome linked to high risk of breast cancer
5. Family history of breast cancer. Indicate if it is member’s first-degree relatives or second-degree relatives (on the same side of the family) and include age of diagnosis, family history of ovarian cancer, and any other high-risk indication (example: Jewish ancestry).
6. History of exposure to heavy doses of ionizing radiation to chest, particularly during youth/adolescence
7. Documentation of member’s ovarian cancer, diagnosed at any age
8. Previous diagnosis of atypical hyperplasia or neoplasia

For MRI of the breast for diagnostic purposes, provide documentation of any of the following clinical situations with authorization request:

1. Suspected occult primary tumor of the breast in a patient with axillary nodal adenocarcinoma and negative physical exam and mammography
2. Presurgical planning before and after neoadjuvant chemotherapy to permit tumor localization and characterization
3. Presurgical planning for clinically localized breast cancer amenable to conservation therapy to evaluate the presence of multicentric disease
4. Posteriorly located breast tumors to determine the extent of tumor invasion of the chest wall

Computed Tomography (CT) Colonography

PrimeWest Health requires authorization prior to performing a CT colonography (74261, 74262, 74263).

Independent Diagnostic Testing Facility (IDTF)

PrimeWest Health follows CMS General Coverage and Payment Policies for IDTF providers.

• Submit the NPI assigned to the ordering physician on the claim.
• When appropriate, bill the TC modifier on diagnostic procedures with a technical component.
• For diagnostic testing performed entirely at the patient’s location, use that location as the place of service (POS). When one or more aspects of the diagnostic testing is performed at the IDTF, the IDTF is the POS.

Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)

When more than one provider is involved in providing and billing a procedure, the providers must establish a written agreement as to which component each provider will bill.

For example, a physician bills for the professional component of the service he/she provided (bill in the 837P format), while the hospital bills for the technical component (on the 837P or 837I format). Or, the hospital bills for the total component (professional and technical on the 837I), and the physician does not bill, but rather is paid by the hospital. Both the physician and the hospital cannot be paid for both components.

When a physician or clinic is billing for services performed and the equipment is owned by either the physician or clinic, the service cannot be separated into a technical and professional component.

CPT or HCPCS and modifiers when required must be used on all claims.

Claims submitted for payment of CT and MRI scans must have a specific medical diagnosis. Use the most complete and highest level of specificity ICD diagnosis code. PET scans are billed using CPT coding.

Computerized Tomography (CT) Scanning Equipment Standards

PrimeWest Health follows Medicare’s requirement that providers must report modifier CT on all computed tomography scans performed on scanning equipment that does not meet the National Electrical Manufacturers Association (NEMA) standards. Refer to MLN Matters MM9250 for more information.

For dates of service between January 1 and December 31, 2016, a payment reduction of 5 percent will apply to the technical component allowable. For dates of service on or after January 1, 2017, a payment reduction of 15 percent will apply to the technical component allowable.

X-rays taken using film

Effective for dates of service on or after January 1, 2017, X-rays taken by film must include modifier FX. PrimeWest Health follows Medicare’s payment incentive to transition from film X-rays to digital radiography. Refer to Pub 100-04 Medicare Claims Processing for more information.

X-rays taken by film will have the technical component allowable amount reduced by 20 percent

Computed Radiography Technology Payment Changes

All X-rays taken using computed radiography technology, defined as cassette-based imaging, must include modifier FY. Refer to Pub 100-04 Medicare Claims Processing for more information.

Payment for X-rays using computed radiography technology will have the technical components allowed amount or the technical component of the global fee allowed amount reduced as follows:

1. For dates of service January 1, 2018 – December 31, 2022, a reduction of 7 percent will apply
2. For dates of service on and after January 1, 2023, a reduction of 10 percent will apply

Professional Component

• Use modifier 26 for professional services that state supervision and interpretation. Do not use modifier 26 if the code is defined as the professional component only.
• Report the appropriate POS
• When a service is rendered to a hospital inpatient, use the inpatient hospital POS code following Medicare guidelines as defined in Medicare Claims Processing Manual.

Technical Component

The technical component includes the charges for personnel, materials, usual contrast media, drugs, film or xenograft, space, equipment, and other facility charges.

The technical component of all inpatient services is included in the inpatient DRG and billed on the 837I claim form.

For a provider transporting his/her own equipment to another site, the technical components may be billed by the provider owning the equipment. To identify a charge for the technical component, enter the procedure code with a TC modifier.

Use the TC modifier only when appropriate. If a CPT code is defined as the technical component only (of a service), do not use the TC modifier.

Injection of contrast material is part of the “with contrast” for CT, CTA, MRI, and MRA procedures.

Total Components

Total components include the technical and professional component. Use the appropriate procedure code without a modifier.

Interventional Radiologic Procedures and Diagnostic Studies with Injection

These types of procedures include professional, technical, and injection components.

Use of radiopharmaceuticals is regulated by the Nuclear Regulatory Commission (NRC) under strict procedures and guidelines. People administering radiopharmaceuticals should have either a license from the NRC or be credentialed by an institution having a board license from the NRC.

Injection Component: Bill radiology procedures using the appropriate CPT code that indicates “with contrast,” if available. Contrast media provided in a hospital must be billed with the appropriate CPT or HCPCS code on the 837I claim form.

Contrast Material: Bill separately using the most appropriate HCPCS code.

Contrast Media Provided in an Inpatient Hospital: Bill the appropriate CPT or HCPCS code on the 837I claim form.

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