Currentpriority healthPolicy 039

HIGH TECH RADIOLOGY SERVICES

Defines billing, coding, documentation and reimbursement guidelines for high-tech radiology services (e.g., MRI, MRA, CT, PET, nuclear cardiology) for Priority Health; applies to commercial and Medicare members and providers submitting claims (excludes ED, inpatient/observation studies).

Policy Summary

Payerpriority health

PolicyHigh Tech Radiology Services

Policy CodePolicy 039

Change TypeCoding, billing, and modifier updates

Effective DateOct 7, 2024

Next Review DateFeb 2, 2025

Key ActionRadiology studies for non-hospital patients must be ordered by the treating practitioner and documented (written, phone, or email orders accepted).

SourceLink

POLICY UPDATE CHANGES

Added 'Disclaimer' section.

Added coding and billing information on radiopharmaceuticals and contrast materials.

Modifiers PI and PS added.

Added a list of CPT codes that are not reimbursed separately for commercial claims.

4+Imaging modalities listed

A9500-A9699HCPCS ranges

76014-76017CPT not reimbursed

0255,0343,0636

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.

N,K2Payment indicators

Coverage and Billing Rules

Coverage and billing rules

Billing and reimbursement rules for high‑tech radiology services, radiopharmaceuticals, and contrast materials.

Services and billing follow Priority Health reimbursement guidance and CMS/MDHHS guidance where applicable; coverage depends on the member's benefit plan and applicable law.

ALL of the following

Radiopharmaceuticals and contrast
- Contrast agents used during an MRI procedure are considered part of the overall reimbursement for the imaging procedure and are not eligible for separate payment.
- Radiopharmaceuticals administered in connection with a PET scan are considered part of the overall reimbursement for the imaging procedure and are not eligible for separate payment.
HCPCS ranges and payment indicators
- Priority Health follows CMS reimbursement guidance for HCPCS codes A9500-A9699 and Q9951-Q9968.
- Payment indicator N indicates no separate payment; payment indicator K2 indicates drugs and biologicals paid separately only when provided integral to an ASC-listed surgical procedure with payment based on OPPS rate.
CPT codes not reimbursed separately for commercial claims
- CPT codes 76014, 76015, 76016, and 76017 are not reimbursed separately for commercial claims.

ALL of the following

Per‑study and per‑mCi billing
- Codes described as 'per study dose, up to 30 millicuries' should be billed as 1 unit when up to 30 mCi is administered.
- Codes described as 'per mCi' should be billed based on the number of millicuries administered (e.g., 5 mCi = 5 units).
NCCI Chapter 9 — radiopharmaceutical injections
- Per NCCI Manual Chapter 9, injection of a radiopharmaceutical is an integral component of a nuclear medicine procedure; vascular access and radiopharmaceutical injection CPT codes (e.g., 36000, 96360-96379) are not separately reportable.
- HCPCS code A9512 (Technetium Tc-99m pertechnetate, per mCi) shall not be reported with other Technetium Tc-99m AXXXX radiopharmaceutical codes for a single nuclear medicine study.
When separate reporting may be required

ALL of the following

This policy does not apply to studies performed during an emergency room visit or during an inpatient or observation unit stay.

Operational guidance: verify member benefit and applicable laws; follow CMS/MDHHS guidance where provided; use appropriate modifiers and units per code descriptors.

Radiopharmaceuticals, Contrast & Billing Units

Radiopharmaceutical / contrast coding guidanceHCPCS | CPT | mixedCovered

A9500-A9699	HCPCS radiopharmaceuticals range followed per CMS guidance
Q9951-Q9968	HCPCS radiopharmaceuticals range followed per CMS guidance
A9512	Technetium Tc-99m pertechnetate; not to be reported with other Technetium Tc-99m AXXXX codes for a single study
76014-76017	CPT codes not reimbursed separately for commercial claims

Radiopharmaceuticals and contrast not separately reimbursedCPT | HCPCSCovered

76014	CPT code listed as not reimbursed separately for commercial claims
76015	CPT code listed as not reimbursed separately for commercial claims
76016	CPT code listed as not reimbursed separately for commercial claims
76017	CPT code listed as not reimbursed separately for commercial claims

Per-study dose billing

Per-study dose ('up to 30 millicuries')Billed as 1 unit when up to 30 mCi is administered

Per mCi codesBilled by the number of mCi administered (e.g., 5 mCi = 5 units)

Injection not separately reportableInjection of a radiopharmaceutical is integral to the nuclear medicine procedure and not separately reportable per NCCI Chapter 9

A9512 reporting restrictionHCPCS A9512 (Technetium Tc-99m pertechnetate, per millicurie) shall not be reported with other Technetium Tc-99m AXXXX radiopharmaceuticals for a single study

Ordering, Documentation, and Audit Requirements

Documentation Required

Ordering and documentation for non-hospital patients — orders must be from treating physician/practitioner; acceptable order methods and required elements.

Diagnostic radiology services provided to commercial or Medicare plan members who are not hospital inpatients or outpatients must be ordered by the treating physician or treating practitioner. A "treating physician" is a physician, as defined in §1861(r) of the Social Security Act, who furnishes a consultation or treats a plan member for a specific medical problem and who uses the results of a diagnostic test in the management of that specific medical problem. A "treating practitioner" is similarly defined (e.g., nurse practitioner, clinical nurse specialist, physician assistant) who, pursuant to State law, furnishes a consultation or treats a member for a specific medical problem and uses the result of a diagnostic test in management of that problem. (Exception: an interpreting physician may order a diagnostic mammogram based on the results of a screening mammogram.)

Ordering physicians must provide diagnostic information to the radiology facility at the time services are ordered.
Radiology services not ordered by the physician/practitioner who is treating the plan member are not covered.
Acceptable order methods: written order signed by the treating physician/practitioner (hand-delivered, mailed or faxed), telephone call from the treating physician/practitioner or their office to the radiology facility, or e-mail from the treating physician/practitioner or their office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner and the testing facility must document the telephone call in their respective copies of the member's medical records.

Key Terms and Components

High tech radiology services

Magnetic Resonance Imaging (MRI)Included among high-tech radiology services

Magnetic Resonance Angiography (MRA)Included among high-tech radiology services

Computed Tomography (CT)Included among high-tech radiology services

Positron Emission Tomography (PET)Included among high-tech radiology services

Nuclear cardiologyIncluded among high-tech radiology services

Global Services

Global service definition

Policy Summary

Payerpriority health

PolicyHigh Tech Radiology Services

Policy CodePolicy 039

Change TypeCoding, billing, and modifier updates

Effective DateOct 7, 2024

Next Review DateFeb 2, 2025

Key ActionRadiology studies for non-hospital patients must be ordered by the treating practitioner and documented (written, phone, or email orders accepted).

SourceLink

On This Page

If two different nuclear medicine procedures are performed on the same day and the radiopharmaceutical used for one cannot be used for the other, separate reporting of the radiopharmaceutical may be appropriate using modifier 59, XE, or XS.

While a physician order is not required to be signed when communicated by telephone, the physician/practitioner must clearly document in the medical record their intent that the test be performed.

Documentation Required

Ordering for hospital patients — orders must be from practitioners with privileges or authorized and must include required elements.

For commercial or Medicare plan members who are hospital inpatients or outpatients, radiology services must be provided only on the order of practitioners with appropriate clinical privileges or, consistent with state law, other practitioners authorized by the medical staff and governing body to order the services (§482.26 Condition of Participation: Radiologic services (b)(4)). There must be an order for all radiology services in the member's medical records, and the order must be dated, timed, and authenticated by an authorized practitioner prior to the time the diagnostic radiology service is performed.

The patient’s medical record must reflect the medical necessity for the care provided; records may include professional provider office notes, hospital records, nursing home records, home health agency records, therapy records, and test reports.
Orders for hospital patients must be by practitioners with privileges or by practitioners otherwise authorized by the facility’s medical staff and governing body.
All orders must be present in the medical record and authenticated before the diagnostic service is performed.

Denial Risk

Audits and documentation availability — Priority Health may conduct reviews/audits and require documentation; failure to produce may result in denial/recoupment.

Priority Health may conduct reviews and audits of services for our members regardless of provider participation status. All documentation supporting the medical necessity and appropriateness of diagnostic radiology services must be available upon request. Failure to produce requested documentation may result in claim denial, payment recoupment, or other corrective action.

Documentation that may be requested includes orders, signed/authenticated records, notes documenting telephone orders, diagnostic information provided to the facility, and supporting medical records showing medical necessity.
Authorization does not guarantee payment; billing and coding must be supported by documentation in the medical record to the highest level of specificity.
If government program regulations, policy, or contractual requirements are not followed, Priority Health may reject or deny the claim and may recover or recoup payment.

A global service includes both a technical element and professional element within the description of the service.

Billing implicationGlobal services may be billed as a combined service when code definition includes both components

Form usageGlobal services may be submitted on UB-04 or CMS-1500 depending on setting

Technical Component

Technical Component (TC)Represents equipment, facility costs and staffing required to perform a service; may be represented with the TC modifier or defined by code as technical services.

Costs includedEquipment, facility overhead, and technical staff expenses are part of the TC.

Billing practiceTechnical component billed using TC modifier when service definition does not already separate components

Professional Component

Professional Component (26)Represents the physician or provider portion of the service (supervision, interpretation, and documentation of reports); identified by modifier 26 or when code defines professional services only.

Services includedInterpretation, report generation, and related professional activities are part of the professional component.

Billing practiceUse modifier 26 to report the professional component when services are split from technical component

Radiopharmaceuticals / Contrast materials

RadiopharmaceuticalsDrugs that contain radioactive isotopes used for medical diagnosis and therapy; they emit radiation enabling detection or treatment of specific tissues or organs.

Contrast materialsSubstances used to enhance visibility of organs, vessels, or tissues during imaging by altering absorption or reflection of energy waves.

Use in proceduresRadiopharmaceuticals and contrast agents are integral to certain imaging procedures and have specific coding and reporting rules per policy and NCCI guidance.