25.3.3.18 Hospital Radiology ServicesProcedure codes 5-93000, T-93005, I-93010, 5-93040, T-93041, and I-94042 will be considered for reimbursement for electrocardiograms if submitted with one of the diagnosis codes in the chart below.
Prior authorization or retrospective authorization is required for:
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• Prior authorization is required for all outpatient nonemergent CT, CTA, MRI, and MRA studies (i.e. those that are scheduled) before services are rendered. Authorization is not required for the emergency department. Retrospective authorization is required for outpatient emergent studies when the physician determines that a medical emergency that imminently threatens life or limb exists, and the medical emergency requires advanced diagnostic imaging (CT, CTA, MRI, or MRA). Providers must submit a retrospective authorization request no later than two business days after the study is completed. The addition of post 3-D reconstruction (76376 and 76377) CT and MR studies must be prior authorized. No additional payment will be made without prior authorization. Obstetrical 3-D reconstruction ultrasound is not a benefit of the Texas Medicaid Program. Refer to: "Radiology Services" , for further information. All medically necessary radiology services provided to hospital clients must be ordered by the client's attending or consulting physician. These services must be documented in the client's medical record. The diagnoses submitted on the claim form should reflect the medical necessity of services rendered. If a diagnosis is not available, TMHP accepts signs and symptoms. TMHP monitors the diagnoses indicated for the following procedures:
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• Repeat Procedures/Modifier 76 The use of modifier 76 is limited as follows:
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• When appealing claims with modifier 76 for repeat non-clinical procedures, providers must separate the details. One detail should be appealed without the modifier and one detail with the modifier, or documentation of times for each repeated procedure. Certain procedure codes have been removed from modifier 76 auditing. These procedure codes have been identified as routinely being performed at the same time, more than twice per day for each antigen (e.g., agglutinins, febrile [e.g., Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus], each antigen). Providers may still appeal claims that have been denied for documentation of time. Most procedure codes initially requiring modifier 76 will continue to be audited for the modifier 76. |
Magnetic resonance imaging (MRI).
