ModifiedEmblemHealthPolicy RP20240020

Radiology-Cardiology-Ultrasound Frequency Rules (Commercial & Medicaid)

Frequency and unit limits for radiology, cardiology, and ultrasound CPT/HCPCS codes for EmblemHealth Commercial & Medicaid products; administered by EviCore/Evernorth and applicable to providers submitting claims to EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyRadiology-Cardiology-Ultrasound Frequency Rules (Commercial & Medicaid)

Policy CodePolicy RP20240020

Change TypeAdded and removed CPT/HCPCS codesformatting/template updates

Effective Date1/1/2026 (for listed code changes)

Next Review Date

Key ActionSubmit billing in accordance with per-code frequency and total units per date of service as administered by EviCore to avoid denials or recoupment.

SourceLink

POLICY UPDATE CHANGES

One Deleted code effective 1/1/2026: 75842

Four New Codes added effective 1/1/2026: 70471, 70472, 70473 and 75577

Removed Asterisk (**) indicating refer to EviCore OBULTRA rules for multiple obstetric ultrasound codes

Archived change noted for code 75565: units changed from 1 to 4 effective 10/01/2023

Policy reformatted and reorganized; content transferred to new template with new Reimbursement Policy Number

Commercial & Medicaidproducts covered

75565=4revised units noted

1/1/2026effective date for code changes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

typical units per DOS

Frequency and Unit Limits — Coverage Criteria

inv-01: Per-code frequency/unit rules (partial list) — examples

Per-code frequency/unit rules (partial list) — listed CPT/HCPCS codes include unit limits, bilateral eligibility, and modifier notes. Each entry denotes total allowed units per date of service and common billing modifiers where specified.

33016 — Pericardiocentesis, including imaging guidance. Bilateral eligible: 50 or LT/RT. Repeated procedure modifier: 76/77. Additional procedure modifier: 59. Total units per DOS: 1.

Use appropriate LT/RT or 50 modifier when bilateral; report 76/77 for repeated procedures and 59 when billed as distinct procedural service.

33017 — Pericardial drainage with insertion of indwelling catheter, percutaneous, incl fluoroscopy and/or ultrasound guidance; 6 years and older without congenital cardiac anomaly. Total units per DOS: 1.

Report single unit per DOS.

33018 — Pericardial drainage with insertion of indwelling catheter, percutaneous, incl fluoroscopy and/or ultrasound guidance; birth through 5 years or any age with congenital cardiac anomaly. Total units per DOS: 1.

Report single unit per DOS.

33019 — Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guidance. Total units per DOS: 1.

Report single unit per DOS.

70010 — Myelography, posterior fossa, radiological supervision and interpretation. Total units per DOS: 1.

Follow bilateral/repeat/additional procedure guidance where applicable.

70015 — Cisternography, positive contrast, radiological supervision and interpretation. Total units per DOS: 1.

Report single unit per DOS.

70030 — Radiologic examination, eye, for detection of foreign body. Bilateral eligible: x. Total units per DOS: 2.

When bilateral, use appropriate modifier and limit units to 2 per DOS.

70100 — Radiologic examination, mandible; partial, less than 4 views. Total units per DOS: 2.

Limit total units per DOS to listed value.

70471 — CTA, head and neck, with contrast, incl noncontrast images and postprocessing. Total units per DOS: 1.

Administered by EviCore for Commercial & Medicaid; follow prior authorization rules.

70472 — CT cerebral perfusion analysis with contrast when performed with concurrent CT/CTA of same anatomy (list separately). Total units per DOS: 1.

List separately in addition to primary procedure when applicable.

70473 — CT cerebral perfusion analysis without concurrent CT/CTA of same anatomy. Total units per DOS: 1.

Report single unit per DOS.

70480 — CT, orbit/sella/posterior fossa/ear without contrast. Total units per DOS: 1.

Follow bilateral eligibility and modifier guidance where applicable.

inv-02: Frequency and unit limit stance — high-level rule

Frequency and unit limits apply to EmblemHealth Commercial & Medicaid products and are administered by EviCore (Evernorth). These rules govern per-date-of-service unit maximums and prior authorization requirements where applicable.

Frequency and unit limits in this section are applicable to Commercial & Medicaid products and are administered by EviCore by Evernorth.

Providers should submit requests to EviCore per their clinical criteria and prior authorization processes.

Limits shown are total units allowed per date of service unless otherwise noted.

Requests exceeding these limits require EviCore review/authorization.

Billing modifiers noted (eg, LT/RT, 50, 76/77, 59) must be applied per standard coding conventions to reflect bilateral services, repeated procedures, or distinct procedural services.

Incorrect modifier usage may result in claim denials or recoupments.

inv-03: Billing attributes (examples) — per-code billing rules

Operational billing attributes and provider instructions — common per-code billing rules, modifier use, and units per DOS examples from the source excerpt.

Apply LT/RT or modifier 50 when code is billed bilaterally and bilateral eligibility is indicated (noted as '50 or LT/RT' or 'x' in entries).

When bilateral eligible is 'x' or specified, ensure only one unit is billed per side consistent with total units per DOS.

Use modifiers 76/77 to indicate repeated procedures when applicable; 76 denotes repeat same physician, 77 denotes repeat by another physician.

Report 76/77 per CMS/modifier guidance to avoid improper payment.

Use modifier 59 for distinct procedural services when an additional procedure is performed and indicated in the code entry.

Document distinct service to support modifier 59 application.

Total units per DOS are explicitly listed for each code; adhere to those limits unless prior authorization by EviCore permits additional units.

Examples include multiple imaging codes with Totals of 1–4 units depending on code (eg, 72295 = 5 units for lumbar discography as noted elsewhere).

inv-04: Per-code frequency and unit rules (partial list) — additional examples

Additional per-code frequency/unit rules — entries include bilateral eligibility and modifier notes where present.

73220 — MRI upper extremity other than joint; without contrast followed by contrast and further sequences. Bilateral eligible: x. Total units per DOS: 2.

Apply LT/RT or 50 modifier as indicated when bilateral.

73221 — MRI any joint of upper extremity; without contrast. Bilateral eligible: x. Total units per DOS: 2.

Limit to two units per DOS; use bilateral modifier when applicable.

73222 — MRI any joint of upper extremity; with contrast. Bilateral eligible: x. Total units per DOS: 2.

Limit to two units per DOS.

73223 — MRI any joint of upper extremity; without contrast followed by contrast and further sequences. Bilateral eligible: x. Total units per DOS: 2.

Report sequences per coding rules up to listed units.

inv-05: Per-code frequency/unit rules (sample) — modifier/bilateral notes

Sample per-code frequency/unit rules demonstrating modifier/bilateral eligibility and unit limits.

73501 — Radiologic exam, hip unilateral with pelvis when performed; 1 view. Total units per DOS: 2.

Some unilateral hip codes may still carry a 2-unit per DOS limit when pelvis included.

73502 — Radiologic exam, hip unilateral with pelvis; 2–3 views. Total units per DOS: 2.

Limit to 2 units per DOS as listed.

73503 — Radiologic exam, hip unilateral with pelvis; minimum of 4 views. Total units per DOS: 2.

Despite multiple views, total units per DOS limited to listed value.

73521 — Radiologic exam, hips bilateral with pelvis; 2 views. Total units per DOS: 2.

When bilateral, ensure correct bilateral modifiers and total units do not exceed listed limit.

inv-06: Frequency/billing rule examples — per-code entries

More per-code frequency and billing rule examples from the excerpt, including unit limits for myelography, discography, and extremity imaging.

72265 — Myelography, lumbosacral, radiological supervision and interpretation. Total units per DOS: 1.

Single unit per DOS unless otherwise authorized.

72270 — Myelography, 2 or more regions; Total units per DOS: 1.

Report per DOS limits; additional regions captured in code descriptor.

72285 — Discography, cervical or thoracic. Total units per DOS: 4.

Discography codes may have higher unit allowances reflecting multiple levels.

72295 — Discography, lumbar. Total units per DOS: 5.

Higher total units per DOS correspond to multiple disc levels tested.

inv-07: Frequency and billing criteria — breast, ultrasound, fluoroscopy examples

Frequency and billing criteria for breast imaging, ultrasound, and fluoroscopic guidance codes — per-code unit limits and modifier guidance.

77001 — Fluoroscopic guidance for central venous access device placement/replacement/removal. Total units per DOS: 2.

When billed in addition to primary procedure, limit to 2 units per DOS as listed.

77002 — Fluoroscopic guidance for needle placement (eg, biopsy, aspiration). Total units per DOS: (follow listed value where present).

Apply appropriate additional listing if used in conjunction with primary procedure.

77053/77054 — Mammary ductogram/galactogram single/multiple ducts. Total units per DOS: 2 for each.

Limit to 2 units per DOS; apply bilateral modifiers if indicated.

77061/77062/77063 — Diagnostic and screening digital breast tomosynthesis codes; Total units per DOS: 1 each.

Bill unilateral/ bilateral codes appropriately; screening bilateral (77063) billed in addition to primary procedure per descriptor.

inv-08: Coverage and billing rules summary

Coverage and billing rules summary — selected codes with reimbursement frequency/unit rules and modifier notes. Administered by EviCore for EmblemHealth Commercial & Medicaid.

Radiology-Cardiology-Ultrasound Frequency Rules apply across the listed CPT/HCPCS codes and are administered by EviCore by Evernorth for EmblemHealth Commercial & Medicaid products.

Providers must follow EviCore clinical criteria and prior authorization processes where applicable.

Total units per date of service are authoritative; listed values (ranging from 1 to 5 in examples) represent maximum billable units per DOS unless EviCore has authorized otherwise.

Claims exceeding listed units may be denied without prior authorization.

Modifier guidance (LT/RT, 50, 76/77, 59) must be applied per code entry notes to reflect bilateral services, repeated procedures, or distinct procedural services.

Accurate coding and documentation are necessary to support modifier use and avoid denials.

Revision history and code set changes (eg, additions effective 1/1/2026) may alter unit allowances or code applicability; consult EviCore and EmblemHealth for current authorization and billing requirements.

CPT / HCPCS Codes and Unit Limits

enumerated procedural imaging codes (partial)CPTCovered

33016-33019	Pericardiocentesis and pericardial drainage codes with guidance details
70010-70371	Various radiologic examination codes (head, mandible, mastoids, facial bones, nasal bones, TMJ, neck, pharynx, etc.) with unit limits
70450-70498	CT head/brain, CT angiography, CT perfusion, CT orbit/maxillofacial/neck with unit limits

Example listed imaging procedure codesCPT

71045	Radiologic examination, chest; single view
71046	Radiologic examination, chest; 2 views
71047	Radiologic examination, chest; 3 views
71048	Radiologic examination, chest; 4 or more views
71100	Radiologic examination, ribs, unilateral; 2 views
71250	CT, thorax, diagnostic; without contrast material
71260	CT, thorax, diagnostic; with contrast material(s)
71550	MRI, chest; without contrast material(s)
72020	Radiologic examination, spine, single view, specify level
72100	Radiologic examination, spine, lumbosacral; 2 or 3 views

Spine myelography/discography codes in this segmentCPT

72255	Myelography, cervical, radiological supervision and interpretation
72265	Myelography, lumbosacral, radiological supervision and interpretation
72270	Myelography, 2 or more regions, radiological supervision and interpretation
72285	Discography, cervical or thoracic, radiological supervision and interpretation
72295	Discography, lumbar, radiological supervision and interpretation

Upper/lower extremity, hip, pelvis, abdomen CT/MRI/radiography codes in these chunksCPT

73000	Radiologic examination; clavicle, complete
73010	Radiologic examination; scapula, complete
73020	Radiologic examination, shoulder; 1 view
73030	Radiologic examination, shoulder; complete, minimum of 2 views
73040	Radiologic examination, shoulder, arthrography, radiological supervision and interpretation
73050	Radiologic examination; acromioclavicular joints, bilateral
73060	Radiologic examination; humerus, minimum of 2 views
73070	Radiologic examination, elbow; 2 views
73080	Radiologic examination, elbow; complete, minimum of 3 views
73085	Radiologic examination, elbow, arthrography, radiological supervision and interpretation

1–10 of 74

1/8

Selected CT/MRI/CTA cardiac and abdominal imaging codesCPTCovered

74170	Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
74174	Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
75574	Computed tomographic angiography, heart, coronary arteries and bypass grafts, with contrast material, including 3D image postprocessing

Selected codes and unit rules from chunks 72-91CPTCovered

75574	CT angiography, heart, coronary arteries and bypass grafts; total units per DOS = 1
75577	Quantification and characterization of coronary atherosclerotic plaque; total units per DOS = 1
75580	Noninvasive estimate of coronary fractional flow reserve (FFR) from CTA; total units per DOS = 1
75600	Aortography, thoracic; total units per DOS = 1
75705	Angiography, spinal, selective; total units per DOS = 20
75710	Angiography, extremity, unilateral; total units per DOS = 2
75716	Angiography, extremity, bilateral; total units per DOS = 1
75726	Angiography, visceral, selective or supraselective; total units per DOS = 3
75774	Angiography, selective, each additional vessel; total units per DOS = 7
75810	Splenoportography; total units per DOS = 1

1–10 of 19

1/2

Sample ultrasound CPT codes and unit rulesCPT | mixedCovered

76770	Ultrasound, retroperitoneal; complete; total units per DOS: 1
76775	Ultrasound, retroperitoneal; limited; total units per DOS: 2
76800	Ultrasound, spinal canal and contents; total units per DOS: 1

Fetal/Extremity ultrasound examplesCPTCovered

76825	Echocardiography, fetal (2D); total units per DOS: 4
76883	Ultrasound, nerve(s) comprehensive per extremity; bilateral eligible; total units per DOS: 4
76881	Ultrasound, complete joint; total units per DOS: 2

Guidance/Interventional imaging examplesCPTCovered

76937	Ultrasound guidance for vascular access; total units per DOS: 2
76942	Ultrasonic guidance for needle placement; total units per DOS: 1
77021	MRI guidance for needle placement; total units per DOS: 1

Breast imaging examplesCPTCovered

77046	MRI breast without contrast; unilateral; total units per DOS: 1
77067	Screening mammography, bilateral; total units per DOS: 1
77063	Screening digital breast tomosynthesis, bilateral; total units per DOS: 1

Radiology/Cardiology/Ultrasound codes in fragmentCPT | HCPCS | mixed

77049	Listed among eligible/repeated/additional procedure entries in this fragment
77053	Mammary ductogram or galactogram, single duct, radiological supervision and interpretation
77054	Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation
77061	Diagnostic digital breast tomosynthesis; unilateral
77062	Diagnostic digital breast tomosynthesis; bilateral
77063	Screening digital breast tomosynthesis, bilateral (add-on)
77065	Diagnostic mammography, including CAD; unilateral
77066	Diagnostic mammography, including CAD; bilateral
77067	Screening mammography, bilateral (2-view) including CAD
77071	Manual application of stress for joint radiography

1–10 of 26

1/3

Listed imaging codes with unit/modifier rulesCPT | HCPCS | mixedCovered

78350/78351	Bone density / dual photon absorptiometry; units and bilateral/repeat/additional indicators listed
78414-78433, 78445, 78451-78454, 78456-78459, 78466-78472, 78473, 78481, 78483, 78491-78494, 78496	Cardiac nuclear imaging (various PET/SPECT/blood pool) with unit and modifier guidance
78579-78582, 78597-78598	Pulmonary ventilation/perfusion and quantitative studies
78600-78610, 78630, 78635, 78645, 78650, 78660	Brain and CSF imaging and related studies
78700-78709, 78725, 78730, 78740, 78761	Kidney, urinary and testicular imaging
78800-78804, 78808, 78811-78816	Radiopharmaceutical localization and PET imaging (various fields/areas)

Sample radiopharmaceutical and PET codesCPTCovered

78804	Radiopharmaceutical localization; planar, whole body; total units per DOS = 1
78808	Injection procedure for radiopharmaceutical localization by non-imaging probe study; total units per DOS = 1
78811	PET imaging; limited area; total units per DOS = 1

Echocardiography and Doppler codesCPTCovered

93319	3D echocardiographic imaging and postprocessing during transesophageal or transthoracic for congenital anomalies; total units per DOS = 1
93320	Doppler echocardiography with spectral display; total units per DOS = 2

inv-23: Total units per DOS (per-code) - summary

Common per-code Total units per DOSMost listed CPT/HCPCS codes include a 'Total units per DOS' allowance (examples shown: 1, 2, 3, 4)

Definition sourceDocument lists 'Total units per DOS' next to each code in the frequency rules tables

Typical rangeExamples in the policy show per-code values from 1 up to 5 depending on procedure

Provider Notices and Administrative Actions

Note

Administrative and notification actions

This policy is administered by EviCore by EVERNORTH on behalf of EmblemHealth. Providers will be notified of policy additions or changes via postings to the Reimbursement Policies webpage on emblemhealth.com and, when appropriate, through updates to the provider manual and provider newsletters emailed to providers with a current email address on file.

Policy administration and utilization management (including Radiology-Cardiology-Ultrasound Frequency Rules) are performed by EviCore by EVERNORTH for Commercial and Medicaid products.
EmblemHealth will inform providers of new policies or changes through the Reimbursement Policies webpage, provider manual updates, and provider newsletters.
Coding edits and claim editing practices follow industry sources (AMA CPT, specialty organizations, CMS/NCCI/MUE); EmblemHealth uses industry-standard claims editing software and may deny or recoup payment if coding/billing guidelines or reimbursement policies are not followed.
Frequency rules and utilization management for the Radiology-Cardiology-Ultrasound program are administered by EviCore by EVERNORTH and apply to Commercial & Medicaid members.

Prior Authorization

Definitions and Modifier Guidance

inv-41: Administrator — EviCore by EVERNORTH

Administrator (context)Policy and frequency rules are administered by EviCore by EVERNORTH

Where statedHeader and multiple entries indicate EviCore administration for Commercial & Medicaid

Provider notificationEmblemHealth will inform providers of changes via website, provider manual and newsletters (policy header)

inv-42: CMS coding edit sources — NCCI and MUE

CMS coding edit sourcesEmblemHealth follows coding edits based on CPT guidelines and CMS sources including NCCI and MUE

Use of industry editsEmblemHealth uses industry-standard claims editing software to apply coding edits

Policy Changes and Revision Notes

2026-01-01code_deletion

Code 75842 deleted effective 1/1/2026.

2026-01-01code_additionsLatest

Codes 70471, 70472, 70473, and 75577 added effective 1/1/2026.

2023-10-01units_revision_archived

Archived change: code 75565 units changed from 1 to 4 effective 10/01/2023.

Policy Summary

PayerEmblemHealth

PolicyRadiology-Cardiology-Ultrasound Frequency Rules (Commercial & Medicaid)

Policy CodePolicy RP20240020

Change TypeAdded and removed CPT/HCPCS codesformatting/template updates

Effective Date1/1/2026 (for listed code changes)

Next Review Date

Key ActionSubmit billing in accordance with per-code frequency and total units per date of service as administered by EviCore to avoid denials or recoupment.

SourceLink

On This Page

When entries indicate 'List separately in addition to code for primary procedure' (eg, 70472), bill as add-on in accordance with coding guidance and ensure prior authorization if required.

Secondary analysis codes performed with a primary study may require separate listing and justification.

73225 — MRA, upper extremity, with or without contrast. Bilateral eligible: x. Total units per DOS: 2.

Follow angiography-specific billing guidance.

73522 — Radiologic exam, hips bilateral with pelvis; 3–4 views. Total units per DOS: 2.

Follow unit cap regardless of number of views.

73000 — Radiologic exam clavicle, complete. Bilateral eligible: x. Total units per DOS: 4.

Apply bilateral modifier when appropriate and limit to 4 units per DOS.

76979 — Ultrasound targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection billed as additional units. Total units per DOS: 3.

List each additional lesion per code descriptor; follow unit limits.

Policy updates are recorded in the document revision history; providers should verify current rules prior to submitting claims.

inv-24: Per date-of-service total units - examples

Chest radiography examples71046 = Total units per DOS: 2; 71048 = Total units per DOS: 1

CT thorax example71250 = Total units per DOS: 2 (71260 also = 2)

Spine example72170/72193 examples shown with Total units per DOS: 1 (72193 = 1)

inv-25: Total units per DOS (per code) - numeric limits

Numeric unit limits per CPTEach CPT entry in the tables specifies a numeric 'Total units per DOS' (examples include 1, 2, 3, 4, 5)

Myelography/discography examples72255 = 1; 72285 = 4; 72295 = 5

Upper extremity MRI/CT examples73200 = 2; 73218 = 2; 73223 = 2

inv-26: Total units per DOS - typical values

Typical per-code valuesMajority of codes list Total units per DOS = 1; some diagnostic/arthrography/series codes list 2 or 4

Examples showing 174160 = 1; 74170 = 1; 74174 = 1

Examples showing >174176 = 2; 74177 = 2; 73721 = 3

inv-27: Total units per DOS — varies by code (examples in chunks 72-91)

Cardiac CTA example75574 = Total units per DOS: 1

Angiography and vascular examples75705 = 20; 75710 = 2; 75726 = 3; 75774 = 7

Ultrasound examples76700 = 1; 76705 = 2; 76770 = 1

inv-28: Total units per DOS — specified per CPT code

Ultrasound and guidance examples76770 = 1; 76775 = 2; 76979 = 3

Fluoroscopy/guidance examples77001 = 2; 77002 = 1; 76998 = 1

Interventional example76979 (targeted dynamic microbubble) = 3

inv-29: Typical total units per DOS — many entries = 1

Breast imaging and mammography examples77049 = 1; 77053 = 2; 77063 = 1

Bone age / survey examples77072 = 1; 77073 = 1; 77074 = 1

DXA examples77078/77080 etc. listed with Total units per DOS = 1

inv-30: Total units per DOS — 1 for the majority of listed codes

Majority-coded valueMany listed CPT/HCPCS codes show Total units per DOS = 1

Modifiers/indicators presentListings also include bilateral eligibility, repeated procedure (76/77), and additional procedure (59) indicators alongside unit values

Cardiac/radiopharm examples78452 = 1; 78804 = 1; 78811 = 1

Frequency rules administration

Utilization management for frequency rules (Radiology-Cardiology-Ultrasound Frequency Rules) is administered by EviCore by EVERNORTH. These frequency rules apply to Commercial and Medicaid products. Providers should follow the frequency limits and claims edits defined by the program; questions about specific coding edits or claim adjudication may be directed to EmblemHealth or EviCore as appropriate.

Radiology-Cardiology-Ultrasound Frequency Rules (Commercial & Medicaid) — Administered by EviCore by EVERNORTH.
Frequency rules define per-date-of-service unit limits, repeat-procedure (76/77) handling, bilateral eligibility, and additional procedure allowances for listed CPT codes.
Providers must adhere to these frequency rules; failure to follow applicable coding/billing guidelines may result in claim denial or recoupment.

Conflict resolutionWhere conflicts between sources occur, EmblemHealth applies the edits it determines appropriate

inv-43: Repeated Procedure - 76/77 — explanation of repeated procedure modifiers

Repeated Procedure modifiers 76/77Modifier 76 indicates a repeated procedure by the same physician; modifier 77 indicates a repeated procedure by another physician (noted in definitions and entries)

Policy entriesMany code lines include a 'Repeated Procedure - 76/77' field to indicate applicability

ExamplesEntries such as 73223 and 74174 show repeated procedure fields present

inv-44: Additional Procedure - 59 — explanation of modifier 59

Additional Procedure modifier 59Modifier 59 indicates a distinct procedural service and is listed where an additional procedure is allowed

Policy usageMany entries include an 'Additional Procedure = 59' field to flag distinct/add-on services

ExamplesCodes such as 73223, 74174 and other CTA/MRI entries include additional procedure notes

inv-45: Radiology-Cardiology-Ultrasound Frequency Rules — definition/ownership

Ownership of frequency rulesRadiology-Cardiology-Ultrasound Frequency Rules (Commercial & Medicaid) are administered by EviCore by EVERNORTH

ScopeApplies to EmblemHealth Commercial & Medicaid products as stated in the header and repeated in entries

Effect on claimsNoncompliance with coding/billing guidelines may result in denial or recoupment as noted in header

inv-46: Modifiers 76/77 and 59 — combined note

Combined note on modifier useEntries include guidance for modifiers 76/77 (repeats) and 59 (distinct service); use as appropriate per code

DocumentationThe policy documents repeat definitions for 76/77 and 59 in the definitions section and per-code rows

ExamplesMultiple code lines show 'Repeated Procedure - 76/77' and 'Additional Procedure - 59' fields

inv-47: Bilateral eligibility indicator

Bilateral eligibility indicatorsBilateral eligibility is indicated per code (examples use .50 or LT/RT or 'x' in the code rows)

Examples74174 shows 'Bilateral Eligible .50 or LT/RT'; 73220/73221 show 'Bilateral Eligible .50 or LT/RT' or 'x'

PurposeIndicator signals whether a code can be billed bilaterally or requires side-specific modifiers

inv-48: Repeated procedure modifier rules (76/77) applicability indicator

Applicability of 76/77 modifier fieldsPer-code rows include a 'Repeated Procedure - 76/77' field to indicate whether repeat-procedure modifiers are applicable

Distinct meaningsDefinitions clarify 76 = repeat by same physician; 77 = repeat by another physician

Examples in tablesSeveral code entries show x or blank for 76/77 indicating applicability per code

inv-49: Use of modifier 59 for additional procedure where noted

Use of modifier 59Policy lists 'Additional Procedure = 59' where a distinct/additional procedure may be billed separate from the primary service

ExamplesCodes across CT/MR/angiography entries include 'Additional Procedure .59' fields to show applicability

Interaction with unitsWhen modifier 59 applies, the per-date-of-service unit allowance remains defined per code in the table

inv-50: Total units per DOS — definition entry

Definition: Total units per DOS'Total units per DOS' denotes the allowed number of units of the CPT/HCPCS procedure that may be billed on a single date of service, specified next to each code in the tables

Where definedTerm appears in definitions and is used consistently across per-code entries

ImplicationExceeding the specified Total units per DOS may lead to claim edits, denials, or recoupment as per policy header

inv-51: Billing modifiers and repeat/bilateral indicators — combined definitions

Billing modifiers and repeat/bilateral indicatorsPolicy rows include 'Additional Procedure = 59', 'Repeated Procedure - 76/77', and bilateral eligible indicators (50 or LT/RT or x) alongside 'Total units per DOS'

Coding editsEmblemHealth applies industry-standard editing and CMS edits (NCCI/MUE) in conjunction with these indicators

Provider actionProviders should include appropriate modifiers (59, 76/77, LT/RT) when billing per-code to avoid denials

inv-52: Total units per DOS — definition repeat

Definition occurrence'Total units per DOS' is reiterated in the definitions and appears in multiple chunks (e.g., 91, 108, 144) as the unit policy field

ConsistencyThe term is consistently used to state allowed units per date of service for each listed code

Documentation noteThe policy's header and code lists together define unit allowances and modifier applicability

inv-53: Repeated Procedure - 76/77 — explanation of 76 vs 77

76 vs 77 distinctionModifier 76 denotes a repeated procedure by the same physician; modifier 77 denotes a repeated procedure by another physician — noted in definitions and entries

Policy placementThis distinction is present in the definitions area and mirrored in per-code rows where 76/77 are referenced

Clinical billing impactUse correct modifier (76 vs 77) per performer to align with the policy's repeat-procedure rules

inv-54: Additional Procedure - 59 — explanation (from chunks)

Modifier 59 short definitionModifier 59 indicates a distinct procedural service and is used where the policy marks 'Additional Procedure = 59'

Policy examplesMany CTA/MRI and other procedure rows include 'Additional Procedure .59' to indicate where 59 may be appropriate

Billing guidanceInclude modifier 59 on claims when billing a distinct/additional procedure as indicated by the policy

inv-55: Modifiers indicating repeated procedures — 76/77 definition

76/77 definition (repeated procedures)Policy entries and definitions state 'Repeated Procedure - 76/77' to indicate applicability of modifiers for repeats

Usage across codesMultiple code rows show 76/77 fields (sometimes marked 'x' when applicable)

Relation to billingApply 76/77 when submitting repeat procedure claims per the policy rules

inv-56: Modifier indicating distinct procedural service / additional procedure — 59 definition

Modifier 59 roleModifier 59 flags distinct procedural services (Additional Procedure) and is listed per-code where applicable

ExamplesEntries for 73223, 74174 and other codes include 'Additional Procedure .59' fields

Billing noteWhen modifier 59 applies, bill the additional distinct procedure with the modifier to reflect policy allowance

inv-57: Indicator for bilateral billing eligibility or side-specific billing — .50 or LT/RT reference

Bilateral indicator formsBilateral eligibility is shown per code using .50 or LT/RT or an 'x' marker in the code rows

Examples74174 shows 'Bilateral Eligible .50 or LT/RT'; many musculoskeletal and imaging codes show 'x' or .50

Billing implicationUse appropriate bilateral or side-specific modifiers when indicated by the code entry

inv-58: Total units per DOS — definition occurrence in chunk 144

Total units per DOS occurrence (chunk 144)Chunk 144 includes 'Total units per DOS' fields for radiopharmaceutical and PET codes (e.g., 78804 = 1, 78811 = 1)

Repetition across documentThe 'Total units per DOS' field appears throughout the code lists (ultrasound, CT, MRI, radiopharm) for consistency

Provider actionRefer to per-code 'Total units per DOS' when billing to ensure units billed per date of service match policy

inv-59: 76/77 — short definition in chunk 144

Short definition: 76/7776/77 indicate repeated procedure modifiers; used in per-code rows to flag repeat-procedure billing rules

Application noteUse 76 or 77 depending on whether the same or another physician performed the repeat procedure

Document presenceChunk 144 and other code rows reference 76/77 in the entries and definitions

inv-60: 59 — short definition in chunk 144

Short definition: 59Modifier 59 denotes an additional or distinct procedural service and is identified in per-code entries where appropriate

Where to useCode rows include 'Additional Procedure = 59' to indicate when 59 may be required for separate billing

Documentation tipWhen billing an additional distinct procedure, append modifier 59 as shown in the policy to align with unit rules

2024-11formatting_reorganization

Policy reformatted and reorganized; content transferred to new template with new Reimbursement Policy Number.