Payment and billing rules for freestanding MRI/MRA services
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Defines which MRI/MRA service codes MassHealth will pay for at freestanding diagnostic and surgical facilities, billing modifiers for technical/professional components, prior authorization and documentation requirements, and where fee schedules are published.
No material clinical or coverage changes in this revision.
Coverage Criteria for Freestanding MRI Centers
Coverage rules for freestanding MRI centers
MassHealth will pay freestanding MRI centers only for the service codes listed in the bulletin and enforces documentation and prior authorization requirements; payment components and billing modifiers are specified.
ALL of the following
ALL of the following
- Services must be provided in accordance with standards developed by the American College of Radiology (ACR).
- For services designated I.C. (individual consideration), a radiology report with the radiologist's interpretation must accompany the freestanding MRI center's claim; payment will be determined based on submitted documentation and illegible or incomplete documentation may result in denial.
- The Division will review claims to verify that services were provided for recommended clinical conditions based on ACR appropriateness criteria.
ALL of the following
- For services designated P.A., the ordering physician must obtain prior authorization from the Division before the delivery of services; no payment will be made unless prior authorization was obtained and retroactive requests are not granted.
- A prior authorization determines only medical necessity and does not waive other prerequisites for payment (for example, member eligibility or other payer availability).
ALL of the following
- The Division has established global, professional, and technical component rates for each listed MRI/MRA service; freestanding MRI centers may be paid either the global rate or the technical component rate for the service provided.
- To bill the technical component, add modifier 'TC' to the end of the service code on the claim form.
- The Division will pay the professional component only to physician providers; freestanding MRI centers will not be paid separately for paramagnetic contrast material because contrast payment is bundled into the MRI/MRA payment.
MRI / MRA Service Codes
| 70336 | Magnetic resonance (e.g., proton) imaging |
| 70540 | Temporomandibular joint MRI (P.A.) |
| 70541 | Orbit, face MRI / neck MRA |
| 70551 | Brain MRI without contrast (I.C.) |
| 70552 | Brain MRI with contrast |
| 70553 | Brain MRI without then with contrast and further sequences |
| 71555 | MRA chest with or without contrast (I.C.) |
| 72141 | Cervical spine MRI without contrast |
| 72142 | Cervical spine MRI with contrast |
| 72146 | Thoracic spine MRI without contrast |
Provider Billing and Action Requirements
Obtain prior authorization for 'P.A.' services
The ordering physician must obtain prior authorization for services designated 'P.A.' in the bulletin. No payment will be made for these services unless prior authorization has been obtained from the Division before the delivery of services; retroactive prior authorization requests will not be granted. Failure to obtain prior authorization will result in claim denial.
- Prior authorization must be obtained from the Division before services are delivered.
- Retroactive prior authorization requests are not granted; claims submitted without prior authorization will be denied.
Include radiology report with I.C. claims
For services designated I.C. (individual consideration), a radiology report including the radiologist's interpretation must accompany the freestanding MRI center's claim. If documentation is illegible or incomplete, the Division will deny the claim; payment will be determined based on submitted documentation.
- Include the radiology report with radiologist interpretation when billing I.C. service codes.
- Ensure documentation is complete and legible to avoid denial; the Division determines payment based on submitted documentation.
Bill technical component with modifier 'TC'
To bill only the technical component of an MRI/MRA service, append modifier 'TC' to the service code on the claim form. The Division will pay freestanding MRI centers either the global rate or the technical component rate; the professional component is paid to physician providers only.
- Add modifier 'TC' to the end of the service code to bill the technical component.
- The Division pays either the global rate or the technical component to freestanding MRI centers; professional component payments go to physician providers.
Definitions
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