Competent revenue cycle management(RCM) is essential for keeping medical practices and hospitals financially healthy. Obtaining prior authorization or approval from health plans to order specific medications, procedures or studies is one of the most challenging aspects of medical billing. The number of imaging studies requiring prior authorization has increased significantly in recent years, adding to the administrative burden. As managing radiology authorization in-house is time-consuming, stressful and costly, most providers rely on insurance authorization services.
Rising Importance of Radiology Procedures
The demand for imaging services has spiked tremendously over the last few decades. Medical imaging is used by a range of medical specialists, from oncologists to internists. It has become essential for almost all major medical conditions, and is the standard of medical care for diseases such as cancer, cardiovascular disease, trauma, and neurological conditions, and many others. Advancements in technology have made imaging faster, more precise imaging and less invasive. This led to the wider use of imaging for more conditions and for more patients. In addition to its utilization for diagnostic purposes, imaging is also used to treat, manage, and predict illnesses.
The increase in the type and volume of imaging procedures has increased the complexity of radiology workflow. Prior authorization requirements add to the challenge.
Prior Authorization Challenges
Many plans utilize prior authorization to determine the appropriateness of medical imaging studies before the procedure is performed by the imaging provider. The primary goal of prior authorizations in radiology is to control over-utilization and inappropriate use of high-cost imaging services.
However, MGMA notes that prior authorizations obstruct the delivery of timely patient care and medical groups are continuing to face “unprecedented challenges stemming from the COVID-19 pandemic. Along with the sharp rise in prior authorization demands, practices reported increased denials, delayed approvals for care, and constantly changing rules. If an authorization is denied, the provider has to appeal or wait 45 days to resubmit the request, further affecting delivery of care.
CPT/HCPCS Codes for Procedures that need Radiology Authorizations
The prior authorization process starts when a specific imaging procedure is recommended for the patient that requires obtaining advance approval from the patient’s health plan to qualify for payment.
The imaging center has to submit preauthorization requests using the appropriate codes. Requirements differ among plans, even those from the same insurance company. Here is a list of CPT/HCPCS codes for some radiology procedures that require preauthorization for the UnitedHealthcare Oxford eviCore Healthcare Arrangement:
CAD
0174T Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure)
MRI
0609T, 0610T, 0611T, 0612T Magnetic resonance spectroscopy
0648T, 0649T Quantitative magnetic resonance for analysis of tissue
70336 MRI TMJ
72141, 72142 MRI Cervical spine
72146, 72147 MRI Thoracic spine
72148, 72149 MRI Lumbar spine
72156-72158 MRI Spine
70551-70553 MRI Head
70554-70555 MRI Brain
70540, 70542 MRI Face
70543 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences
72195-72198 MRI Pelvis
73218-73223 MRI Upper extremity
73718-73723 MRI Lower extremity
71550-71550 MRI Chest
74181-74183 MRI Abdomen w/o contrast
74712, 74713 Magnetic resonance imaging fetal
76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation
76390 MRI spectroscopy
76391 Magnetic resonance (e.g., vibration) elastography
76498 Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)
76499 Unlisted procedure
77021, 77022 Magnetic resonance imaging guidance
77046-77049 Magnetic resonance imaging, breast
77084 MRI Bone marrow blood supply
77021, 77022 Magnetic resonance imaging guidance
77084 MRI Bone marrow blood supply
C8900- C8902 Magnetic resonance angiography abdomen
C8903, C8905, C8906, C8908 Magnetic resonance imaging breast
C8909- C8911 Magnetic resonance angiography chest
C8914, Magnetic resonance angiography lower extremity
C8918-C8920 Magnetic resonance angiography pelvis
C8931- C8936 Magnetic resonance angiography
C8937 Computer-aided detection, including computer algorithm analysis of breast MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for
interpretation (list separately in addition to code for primary procedure)
S8037 Magnetic resonance cholangiopancreatography (MRCP)
S8042 Magnetic resonance imaging (MRI), low-field
CT Scan
0623T, 0624T, 0625T, 0626T Automated quantification and characterization of coronary atherosclerotic plaque
0633T, 0634T, 0635T, 0636T, 0637T, 0638T Computed tomography, breast,
70450 Computed tomography, head or brain; without contrast material
70460 CT Head/brain w/ contrast
70470 CT Head/brain w/o & w/ contrast
70480, 70481, 70482 Computed tomography, orbit
70486-70488 Computed tomography, maxillofacial area
70490-70492 Computed tomography, soft tissue neck
70496, 70498 CT Angiography
71250, 71260, 71270, 71271 Computed tomography, thorax
71275 CT angiography, chest (noncoronary)
72125 Computed tomography, cervical spine; without contrast material
72126, 72126 CT C Spine
72128-72133 Computed tomography, thoracic spine
72191 CT Angiography pelvis
72192, 72193, 72194 CT pelvis
73200-73202 CT Upper extremity
73206 CT Angiography upper extremity
73700-73702 Computed tomography, lower extremity
73706 CT Angiography lower extremity
74150, 74160, 74170 Computed tomography, abdomen
74174 CT angiography, abdomen and pelvis, with
contrast material(s), including noncontrast images, if performed, and image postprocessing
74175 CT Angiography abdomen
74176-74178 Computed tomography, abdomen and pelvis
74261-74263 Computed tomographic (CT) colonography
75635 CT Angiography abdominal aorta and bilateral iliofemoral lower extremity runoff
76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation
76380 CT Limited or localized follow-up study
76497 Unlisted computed tomography procedure (e.g., diagnostic, interventional)
MRA
70544-70546 MRA Head
70547-70549 MRA Neck
72159 MRA Spinal canal w/ or w/o contrast
73225 MRA Upper extremity w/ or w/o contrast
74185 MRA Abdomen w/ or w/o contrast
71555 MRA Chest (exc myocardium) w/ or w/o contrast
Obstetrical Ultrasound
76801-76802, 76805, 76810 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< or = 14 weeks 0 days)
76811, 76812 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach
76813, 76814 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation
76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position, and/or qualitative amniotic fluid volume), one or more fetuses
76816 Ultrasound, pregnant uterus, real time with image documentation, follow up (e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach per fetus
76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal; for non-obstetrical transvaginal ultrasound use 76830; If transvaginal examination is done in addition to transabdominal obstetrical ultrasound exam, use 76817 in addition to appropriate transabdominal exam code
76818, 76819 Fetal biophysical profile
76820, 76821 Doppler velocimetry, fetal
76825 Echocardiography, fetal, cardiovascular system, real time w/image documentation (2d), w/ or w/o m-mode recording
76826 Follow up or repeat study
76827 Doppler echocardiography, fetal, cardiovascular system, pulsed wave and/or continuous wave w/spectral display, complete
76828 Follow up or repeat study
76975 Endoscopic ultrasound
Nuclear Medicine
78012 Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)
78013, 78014 Thyroid imaging
78015, 78016 Thyroid met imaging
78018 Thyroid scan whole body
78020 Thyroid carcinoma metastases uptake
78070-78072 Parathyroid planar imaging
78075 Adrenal nuclear imaging
78099 Unlisted endocrine procedure, diagnostic nuclear medicine
78102-78104 Bone marrow imaging, limited
78185 Spleen imaging w & w/o vascular flow
78195 Lymph system imaging 0
78199 Unlisted hematopoietic diagnostic nuclear medicine
78201, 78202 Liver imaging
78215, 78216 Liver & spleen imaging
78226, 78227 Hepatobiliary system imaging
78230 Salivary gland imaging
78231 Serial salivary gland
78232 Salivary gland function exam
78258 Esophagus motility study
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux exam
78264-78266 Gastric emptying imaging study
78278 GI Bleeder scan
78282 GI Protein exam
78290 Meckel’s diverticulum imaging
78291 Leveen shunt patency exam
78299 Unlisted gastrointestinal procedure
78300, 78305 Bone or joint imaging ltd
78306 Bone scan whole body
78315 Bone scan 3 phase study
78399 Unlisted musculoskeletal procedure
78414 Non-imaging heart function
78445 Radionuclide venogram non-cardiac
78456 Acute venous thrombosis imaging, peptide
78457, 78458 Venous thrombosis imaging
78499 Unlisted cardiovascular nuclear exam
78579 Pulmonary ventilation imaging (e.g., aerosol or gas)
78580 Pulmonary perfusion imaging
78582 Pulmonary ventilation (e.g., aerosol or gas) and perfusion imaging
78597, 78598 Quantitative differential pulmonary perfusion
78599 Unlisted respiratory nuclear exam
78600, 78601, 78605, 78606 Brain imaging
78610 Brain flow imaging only
78630 Cisternogram (cerebrospinal fluid flow)
78635 Cerebrospinal ventriculography
78645 CSF Shunt evaluation
78650 CSF Leakage detection and localization
78660 Radiopharmaceutical dacryocystography
78699 Unlisted diagnostic nuclear med procedure
78700, 78701, 78707-78709 Kidney imaging
78725 Kidney function study – non-imaging radioisotopic
78730 Urinary bladder residual study
78740 Ureteral reflux study
78761 Testicular imaging w/ vascular flow
78799 Unlisted genitourinary procedure
78800 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular
flow and blood pool imaging, when performed); planar, single
area (e.g., head, neck, chest, pelvis), single day imaging
78801, 78802-78804, 78830-78832 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s)
78999 Unlisted misc. procedure
S8080 Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical
PET Scan
78429, 78430, 78431-78433 Myocardial imaging, positron emission tomography (PET)
78608, 78609 Brain imaging, positron emission tomography (PET)
78811-78813 PET imaging; limited area (e.g., chest, head/neck)
78814-78816 PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging
G0235 PET imaging, any site, not otherwise specified
G0252 PET, full and partial ring PET Scanners only for initial diagnosis of breast cancer and/or surgical planning for breast cancer
S8085 Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dualhead coincidence detection system (nondedicated PET scan)
Preventing Prior Authorization Denials
Prior authorizations are challenging as insurance companies can deny a claim for a radiology services for various reasons:
- Not meeting payer guidelines
- Failure to obtain prior authorization before the exam was performed
- Incorrect or incomplete information about the exam
- Outdated insurance information such as the policy has expired
- Procedure is not medically necessary
- Experimental
- Incorrect codes, and other errors
In addition to the CPT-HCPCS code, prior authorization requests have to include the specific ICD-10 diagnosis code.
Due to the complexity of the process and the frequently changing rules and procedures of insurance companies, it can be difficult for imaging center staff to manage. Outsourcing the task to a medical billing company that provides comprehensive insurance verification and authorization support is the best solution. These companies have insurance authorization and verification specialists who are well-versed of which plans require prior authorizations, which radiology procedures within each plan require authorization, and how to obtain the authorization. In addition to obtaining and verifying the patient eligibility prior to the provision of service, they will ensure that the prior authorization request is submitted with the appropriate codes, documentation, and according to the plan’s guidelines. Working with an expert can help imaging centers increase revenue, improve provider and patient satisfaction, and prevent delays in patient care.
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