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26.2.1 Reimbursement for Radiology Services Provided by or at Physician Offices or Clinics
In compliance with Health and Human Services (HHS) regulations, physicians, advanced practice nurses (APNs), physician groups, and clinics may not submit radiology services provided outside of their offices. These services must be submitted directly by the facility or provider that performs the service. This regulation does not affect services performed by the physician or others under his or her personal supervision in the physician's office. To provide Texas Medicaid Program services, each nurse practitioner (NP) or clinical nurse specialist (CNS) must be licensed as a registered nurse and recognized as an APN by the Texas Board of Nursing (BON).
For services provided by physicians in their offices or clinics, providers may submit total or technical components, as applicable, for procedures that were performed using equipment owned by that physician and located in that physician's office. The technical component is denied when submitted by a physician in the inpatient or outpatient hospital setting. If the physician is a member of a clinic that owns and operates radiology facilities, the physician may submit these services. However, if the physician practices independently and shares space in a medical complex where radiology facilities are located, the physician may not submit these services even if he or she owns or shares ownership of the facility, unless the physician personally supervises and is responsible for the daily operation of the facilities.
If a physician owns equipment and performs studies in his or her office, but has a radiologist come to the office to perform the interpretations, the physician may submit all services connected with the study and may reimburse the radiologist for an interpretation or the physician may submit the technical component and allow the interpreting physician to submit the interpretation separately. A separate charge for radiology interpretation submitted by the attending or consulting physician is not allowed concurrently with that of the radiologist. Interpretations are considered part of the attending or consulting physician's overall work-up and treatment of the client. Providers who perform the technical service and interpretation must submit the total component. Providers who perform only the technical service must submit the technical component. Providers who perform only the interpretation must submit the only interpretation component. Claims filed in excess of the amount allowed for the total component for the same procedure submitted with the same date of service, for the same client, any provider, are denied.
Claims are considered for reimbursement based on the order in which they are received. For example, if a claim is received for the total component, and TMHP has already made payment for the technical and/or interpretation component for the same procedure, submitted with the same dates of service, for the same client by any provider, the claim for the total component is denied. The same is true if a total component has already been paid and claims are received for the individual components.
Providers other than radiologists are sometimes under agreement with facilities to provide interpretations in specific instances. Those specialties may be reimbursed if a radiologist is not submitting the interpretation component of radiology procedures.
If duplicate submissions are found between a radiologist and other specialties, the radiologist's claim is considered for reimbursement and the other providers are denied.
Abdominal flat plates (AFP) or kidneys, ureters, and bladder (KUB) procedures (procedure codes 4/I/T-74000, 4/I/T-74010, and 4/I/T-74020) are frequently taken as preliminary X-rays before other, more complicated procedures. If a physician submits an AFP or KUB separately and a more complicated procedures submitted with the same date of service, the charges are combined and the more complex procedures are considered for reimbursement. If, however, the claim specifically states that the AFP or KUB was done first, and the results required further radiographic procedures, each procedure is considered for reimbursement separately.
Oral preparations for X-rays are included in the charge for the X-ray procedure. Separate charges for oral preparations are denied as part of another procedure submitted with the same date of service.
Separate charges for injectable radioactive materials used in the performance of specialized X-ray procedures are considered for payment.
Intraoperative ultrasonic guidance is considered a part of a surgical procedure and is not a benefit of the CSHCN Services Program. Portable X-ray services are not benefits of the CSHCN Services Program.
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