Current through Register Vol. 56, No. 18, September 16, 2024
(a) For documented, necessary, combined abdominal and pelvic body scans (CT and/or MRI), reimbursement for the second or subsequent procedures shall be limited to an additional 50 percent of the payment for the first procedure.
(b) For computerized tomography scan (CT) guidance (monitoring) performed in conjunction with biopsy, aspiration, puncture, injection of contrast material, or placement of a tube, drain, or other medically necessary device, the HCPCS codes with modifier for Reduced Services "-52" shall be used for billing purposes.
(c) Magnetic resonance imaging (MRI) shall be considered a covered service when provided in an inpatient or outpatient hospital setting, in an MRI consortium or in a physician's office. Reimbursement shall be contingent upon the provider of service and place of service.
1. When a hospital submits a claim for charges for an MRI service provided to an inpatient or outpatient, the technical component (TC) shall be separated from the professional component (PC).
i. The charge for the technical component (TC) provided to a hospital inpatient shall be billed by the hospital where the patient is registered as an inpatient, irrespective of where the MRI service is performed. When a hospital is providing an MRI service to an inpatient of another hospital, the hospital providing the service bills the charge to the referring hospital for reimbursement and the referring (inpatient) hospital bills the "rebundled charge" to the Medicaid/NJ FamilyCare program.
ii. The technical component (TC) provided to a hospital outpatient shall be billed by the hospital. The charge is subject to the Medicaid/NJ FamilyCare cost-to-charge ratio. (See N.J.A.C. 10:52.)
iii. For both hospital inpatients and outpatients, the professional component shall be billed on the CMS 1500 claim form, either by the physician or by the MRI-based hospital on behalf of the physician, and not on any other form.
2. MRI services provided by a consortium to a hospital inpatient shall be billed as follows:
i. For reimbursement of the "TC", the consortium shall bill charges to the hospital where the patient is registered as an inpatient, using the "TC" modifier. For reimbursement of the "PC", the consortium shall bill the amount in the "PC" column of the Medicaid maximum fee allowance, using the modifier "26."
ii. For reimbursement for MRI services provided to other than a hospital inpatient by a consortium, the professional component (PC) and technical component (TC) shall not be split. The composite (global) rate listed in 10:54-9.6 in the last column, entitled "Maximum fee allowance," shall be billed to Medicaid, using the CMS 1500 claim form.
3. For reimbursement for MRI services provided by a physician in an office setting to a beneficiary who is not a hospital inpatient, the technical component (TC) and the professional component (PC) shall not be split. The composite (global) rate shall be billed to the Medicaid/NJ FamilyCare program, using the CMS 1500 claim form.
4. For the limitations on the use of procedure codes for ultrasound services to a beneficiary who is pregnant (using the HCPCS 76805, 76810, and 76815 for billing) refer to the qualifier section of 10:54-9.8.
