39.3.1 Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)CT imaging, computed tomography angiography (CTA), MRI, and magnetic resonance angiography (MRA) services are benefits of the Texas Medicaid Program. CT combines the use of a digital computer and a rotating X-ray device to create detailed cross-sectional images or "slices" of organs and body parts, such as the lungs, liver, kidneys, pancreas, pelvis, extremities, brain, spine, and blood vessels. CT provides a detailed image of bony structures. CTA is used to visualize blood flow in arterial and venous vessels. Note: Providers and facilities are required to use the lowest possible radiation dose consistent with acceptable image quality for CT examinations of children. It is recommended that providers and facilities utilize national standards for CT imaging, such as the American College of Radiology's, "Practice Guidelines for Performing and Interpreting Diagnostic CT Examinations." MRI uses magnetic energy and radio waves to create cross-sectional images or "slices" of the human body. MRI is an effective diagnostic tool for detecting defects, diseases, and trauma. It is used to image many types of soft-tissue, including, but not limited to, the central nervous system, internal organs, and the musculoskeletal system. MRA is an MRI study of the arterial and venous blood vessels. MRA utilizes MRI technology and is used as an effective diagnostic tool to detect, diagnose, and aid the treatment of heart disorders, stroke, and blood vessel diseases. Note: Additional or alternate studies identified and ordered by the radiologist at the time of a prior authorized study meet the definition of an urgent condition. Authorization is not required for emergency department or inpatient hospital radiology services. Prior authorization is required for outpatient non-emergent CT, CTA, MRI, and MRA studies (i.e., those that are preplanned or scheduled) before rendering the service. The following procedure codes require authorization:
A request for retrospective authorization must be submitted no later than seven calendar days beginning the day after the study is completed. Retrospective authorization is required for outpatient emergent studies if the physician determines a medical emergency that imminently threatens life or limb exists, and the medical emergency requires advanced diagnostic imaging (CT, CTA, MRI, or MRA). Retrospective authorization is required for outpatient urgent studies if the radiologist determines, during the provision of prior authorized services, that additional or alternate procedures are medically indicated, and that the urgent condition requires additional or alternate advanced diagnostic imaging (CT, CTA, MRI, or MRA). The addition of post-three-dimensional reconstruction (procedure codes 4/I/T-76376 and 4/I/T-76377) CT, CTA, MRI, and MRA studies requires authorization if the authorization request is for outpatient, elective, diagnostic CT, CTA, MRI, and MRA imaging studies. Three-dimensional obstetric ultrasounds are not a benefit of the Texas Medicaid Program. Prior authorization of nonemergent and retrospective authorization of urgent or emergent CT, CTA, MRI, and MRA studies will be considered on an individual basis that adheres to standard clinical evidence-based guidelines. Documentation must support the medical necessity of the study and must be maintained in the client's record by the ordering physician and the radiologist. Note: The authorization processes for emergent and nonemergent studies use nationally accepted guidelines and radiology protocols that are based on medical literature. Nationally accepted guidelines and protocols include those produced by the American College of Radiology (specifically, their Appropriateness Criteria), American Academy of Neurology, American Academy of Orthopedic Surgeons, American College of Cardiology, the American Heart Association, and the National Comprehensive Cancer Care Network. Providers may request prior or retrospective authorization by calling the TMHP Radiology Services Prior Authorization Line at 1-800-572-2116, by fax to 1-888-693-3210, or by mail to:
Texas Medicaid & Healthcare Partnership Providers that make requests for authorization by phone must provide the following information:
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• Providers that make requests by fax or mail must complete and maintain the Radiology Authorization Form. The form must document the medical necessity of the test, including diagnosis, treatment history, treatment plan, medications, and previous imaging results. Providers may be asked to provide additional documentation. Section 1 of the Radiology Authorization Form must be completed, signed, and dated by the ordering physician before requesting prior authorization for a CT, CTA, MRI or MRA. Section 2 of the Radiology Authorization Form must be completed, signed, and dated by the radiologist before requesting retrospective authorization for urgent or emergent studies. Residents, physician assistants, and nurse practitioners may order radiological procedures; however, the ordering/referring clinician must sign the authorization form and use the group or supervising provider's provider identifier. The completed form with original signature must be maintained in the client's medical record by the physician who ordered the tests. Note: The physician's signature must be current, unaltered, original, and handwritten. A computerized or stamped signature will not be accepted. Reimbursement for outpatient emergent and nonemergent CT, CTA, MRI, and MRA studies requires the authorization number on the claim at the time of claim submission. When billed with the CMS-1500 claim form, claims for emergency CT, CTA, MRI, and MRA studies that were provided in an emergency department must be submitted with modifier U6 and the corresponding emergency services code to be considered for reimbursement. When billed with the CMS-1450 claim form, claims submitted for emergency CT, CTA, MRI, and MRA studies that were provided in an emergency department must be submitted with the appropriate corresponding emergency services revenue code to be considered for reimbursement. If two radiology CTs, CTAs, MRAs, or MRIs are performed in the emergency room and/or an outpatient setting on the same day without an authorization on file, the second procedure is denied. Providers may submit additional medical necessity documentation for payment reconsideration.
Intraoperative MRIs of the brain (procedure codes The authorization requirements for both nonemergent and emergent studies must be met to be considered for reimbursement. If there is no authorization, both the technical and professional interpretation components are denied. Refer to: "Hospital (Medical/Surgical Acute Care Facility)" . "Physician" for more information on MRI and contrast material. |
Diagnosis.
