405 IAC 5-27-1; 405 IAC 5-27-2; 405 IAC 5-27-3; 405 IAC 5-27-6; 405 IAC 5-27-7; 405 IAC 5-27-8; 405 IAC 5-27-9

(1) Prior authorization is required for any radiological services that exceed the utilization parameters set out in this article.

(2) To be eligible for reimbursement, a radiological service must be ordered in writing by a physician or other practitioner authorized to do so under state law.

(3) Radiological service facilities must bill Medicaid directly for components provided by the facility. When two (2) practitioners separately provide a portion of the radiology service, each practitioner shall bill Medicaid directly for the component he or she provides. Medicaid will reimburse a physician or other practitioner for radiological services only when such services are performed under the physician's or practitioner's direct supervision.

(1) CPT codes for supervision and interpretation procedures will not be reimbursed when the same provider bills for the complete procedure CPT code.

(2) If two (2) provider specialties are performing a radiology procedure, the radiologist shall bill for the supervision and interpretation procedure with the second physician billing the appropriate injection, aspiration, or biopsy procedure.

(3) Angiography procedures when performed as an integral component of a surgical procedure by the operating physician will not be reimbursed. Such procedures include, but are not limited to, the following:

(1) Evidence that this radiologic procedure is necessary for the appropriate treatment of illness or injury.

(2) X-rays of the spinal column are limited to cases of acute documented injury or a medical condition where interpretation of x-ray films would make a direct impact on the medical/surgical treatment.

(3) Medicaid reimbursement is available for x-rays of the extremities and spine for the study of neuromusculoskeletal conditions.

(4) Radiologic procedures must be limited to the minimum number of views or films in order to appropriately diagnose or assess a patient condition. Procedures must also be limited to the most appropriate body part or area to provide or rule out a diagnosis for the suspected condition.

(4) (5) Medicaid reimbursement is not available for radiology examinations of any body part taken as a routine study not necessary to for the diagnosis or treatment of a medical condition. Situations generally not needing radiologic services include, but are not limited to, the following:

(1) The scan should be reasonable and necessary for the individual patient.

(2) The use of a CT scan must be found to be medically appropriate necessary considering the patient's symptoms and preliminary diagnosis.

(3) Reimbursement will be made only for CT scans that have been performed on equipment that has been certified by the Food and Drug Administration.

(4) Whole abdomen, or whole pelvis on greater than twenty (20) cuts will not be reimbursed except in staging cancer for treatment evaluation.

(1) Sonography exams performed during pregnancy when warranted by one (1) or more of the following conditions:

(2) Venous Doppler exams for blood flow.

(3) Diagnostic exams of soft tissues or organs.

(4) Echocardiograms.

(5) Other sonography exams as determined by the office.

LSA Document #18-375(F)

Notice of Intent: 20180912-IR-405180375NIA

Proposed Rule: 20190703-IR-405180375PRA

Hearing Held: July 25, 2019

Approved by Attorney General: September 6, 2019

Approved by Governor: September 10, 2019

Filed with Publisher: September 11, 2019, 9:52 a.m.

Documents Incorporated by Reference: None Received by Publisher

Small Business Regulatory Coordinator: Michael Cook, Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning, Indiana Government Center South, 402 West Washington Street, Room W374, Indianapolis, IN 46204, (317) 232-7050, michael.cook@fssa.in.gov