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Issue Number - Name
0146-Unbundling of CT Scans
Review Type
Automated
Claim Type
Outpatient Hospital, Professional Services
Region and State
RAC 1-4
All States
Date Approved
02/05/2019

Description

When a more extensive CT Scan is performed on the same site as a less extensive CT Scan, the less extensive CT Scan is bundled into the more extensive CT Scan.  The Medicare Claims Processing Manual, Chapter 12, Section 30. H. and J  indicates that the HCPCS Codes for CT Scans defined as “with”, “without” and “with and without” should not be simultaneously billed. This query identifies multiple units of CT Scans billed on the same day by the same provider for the same Beneficiary. The most extensive code should be the only code paid. The less extensive CT Scan code(s) will be recovered as overpayments.

Affected Codes

70450, 70460, 70470, 70480-70482, 70486-70488, 70490-70492, 71250, 71260, 71270

72125-72133, 72192-72194, 73200-73202, 73700-73702, 74150, 74160, 74170, 74176-74178

74261-74262

Applicable Policy References

Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)-Exclusions from Coverage and Medicare as a Secondary Payer
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1833(e)-Payment of Benefits
42 CFR Section 405.980-Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor, and (c)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
42 CFR Section 405.986-Good Cause for Reopening 
CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3-Verifying Potential Errors and Taking Corrective Actions, Section 3.2.3.8-No Response or Insufficient Response to Additional Documentation Requests
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12-Physicians/Non-physician Practitioners, Sections 30H-Most Extensive Procedures and J-With/Without Procedures, Effective 10/1/03
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.2-Fee Schedule Administration and Coding Requirements
NCCI Policy Manual for Medicare Services Chapter 1A
CPT Manual year 2015 to current