General Guidelines for Prior Authorizations
MRI, when performed in Food and Drug Administration approved units, may be
authorized when it is documented that (1) otehr information or techniques cannot
establish the presumptive diagnosis. (2) a less costly service would not
aequately meet the patient's medical needs. and (3) MRI is not
contraindicated.
MRI is not reimbursable when used to verify the
existence of lesions already identified by
Computerized Tomography
(
CT-Scan), sonographic
evaluation, or other comparable diagnostic methods.
Treatment Authorization Requests (TARs) must be accompanied
by the following supportive documentation: complete history and physical, copies
of X-ray reports (must have had X-Rays and/or CT Scans done), and justification
that other techniques were inadequate for diagnosis. The TAR should be signed by
the referring physician (and printed below the signature).
Billing for MRI
If two or more modifiers are necessary to identify a radiological procedure. Use
modifier -99 on the claim line, and list and explain the applicable modifiers in
the
Remarks area/
Reserved for Local Use field (Box 19) of the
claim. Refer to Section 200-125
Surgeries for further instructions about
using modifier -99.
Reimbursement for MRI services is notbased on the
number of sequences performed: therefore documentation of the need for sequences
is not required.
TAR for Split-Billed
When requestiong a TAR for split-billed MRI codes, indicate MRI authorization is
being requested for both modifier -ZS (professional component) and modifier -TC
(technical component). One provider may obtain the TAR for both providers of
service by noting to the field office that two lines: one with modifier -26, the
other with modifier -TC; need to be authorized. By requesting the TAR in this
manner, both providers may bill from the same TAR.
Note: This procedure is not necessary if both services have been performed
by the same provider. Modifier -ZS would be used for authorization in this case.