Portable X-Ray Services

Portable X-Ray Services
42 CFR 486.106 outlines the specific conditions for coverage for portable X-ray examinations. The regulations summarize the 'referral for service' and 'preservation of records' for portable X-ray examinations, they are as follows:

Referral of Services
Portable X-ray examinations are performed only on the order of a physician licensed to practice in the state or by a nonphysician practitioner acting within the scope of state law. The supplier's records show that:

• The portable X-ray test was ordered by a licensed physician or a nonphysician practitioner acting within the state scope of law and
• Such physician or nonphysician practitioner’s written, signed order specifies the reason a portable X-ray test is required, the area of the body to be exposed, the number of radiographs to be obtained, and the views needed; it also includes a statement concerning the condition of the patient which indicates why portable X-ray services are necessary.

Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary, and therefore, would not be a covered service under the Medicare program.

Preservation of Records
The portable X-ray supplier should create for each patient a record of the date of the portable X-ray examination, the name of the patient, a description of the procedures ordered and performed, the referring physician or nonphysician practitioner, the operator(s) of the portable X-ray equipment who performed the examination, the physician to whom the radiograph was sent, and the date it was sent.

Such reports are to be maintained for a period of at least two years, or for the period of time required by State law for such records (as distinguished from requirements as to the radiograph itself), whichever is longer.

In 42 CFR 424.5 (A) (6), it's stated that, ‘The provider, supplier or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.’ The patient’s medical records should contain enough information to substantiate the claim submitted to Medicare. For portable X-ray services, that includes the documentation outlined above in the ‘Referral of Services’ section. If required information is missing in the submitted medical record, the claim will be considered invalid, and steps will be taken to recover Medicare funds from the supplier.

Additional Portable X-ray Requirements
Diagnostic X-ray services furnished by a portable X-ray supplier are covered under Part B when furnished in a place or residence used as the patient’s home and in non-participating institutions. These services must be performed under the general supervision of a physician, the supplier must meet FDA certification requirements and certain conditions relating to health and safety must be met.

Diagnostic portable X-ray services are also covered under Part B when provided in participating skilled nursing facilities (SNFs) and hospitals under circumstances in which they cannot be covered under hospital insurance (e.g., the services are not furnished by the participating institution either directly or under arrangements that provide for the institution to bill for the services).

Scope of the Portable X-ray Benefit
In order to avoid payment for services which are inadequate or hazardous to the patient, the scope of the covered portable X-ray benefit is defined as:

• Skeletal films involving arms and legs, pelvis, vertebral column and skull
• Chest films which do not involve the use of contrast media (except routine screening procedures and tests in connection with routine physical examinations)
• Abdominal films which do not involve the use of contrast media
• Diagnostic mammograms if the approved portable x-ray supplier, as defined in 42 CFR part 486, subpart C, meets the certification requirements of section 354 of the Public Health Service Act, as implemented by 21 CFR part 900, subpart B

Exclusions from Coverage as Portable X-ray Services
Procedures and examinations which are not covered under the portable X-ray provision include the following:

• Procedures involving fluoroscopy
• Procedures involving the use of contrast media
• Procedures requiring the administration of a substance to the patient or injection of a substance into the patient and/or special manipulation of the patient
• Procedures which require special medical skills or knowledge possessed by a doctor of medicine or doctor of osteopathy or which require that medical judgment be exercised
• Procedures requiring special technical competency and/or special equipment or materials
• Routine screening procedures
• Procedures which are not of a diagnostic nature

HCPCS Codes
The following HCPCS codes should be used as a guide when submitting claims for transportation and set up of portable X-ray equipment.

These codes represent the transportation of the equipment to the patient. The transportation charge is not payable unless the portable X-ray equipment used was actually transported to the location where the X-ray was taken. Suppliers should not bill for a transport fee when the X-ray equipment is stored in a facility for use as needed. If the X-ray is not covered, the transportation and set up will also be non-covered.

Providers may not submit claims for transport or set-up fees in conjunction with electrocardiograms (EKGs).

Coding Guidelines

• Portable X-ray tests must be provided on the written order of a physician or nonphysician practitioner. The ordering provider’s name and NPI must be included on the claim submitted to Medicare by the portable X-ray supplier.
  • Ordering/Referring provider’s name and qualifier DN or DK.
    • Paper claims – Item 17 of the CMS 1500
    • Electronic claims - HIPAA ANSI v5010 Loop, Segment, and Element:
      • Ordering Provider Last Name: Loop 2420E, NM1/DK, 03
      • Ordering Provider First Name: Loop 2420E, NM1/DK, 04
      • Referring Provider Last Name: Loop 2420F, NM1/DN, 03
      • Referring Provider First Name: Loop 2420F, NM1/DN, 04
  • Ordering/Referring provider’s National Provider Identifier (NPI)
    • Paper claims – Item 17b of CMS 1500
    • Electronic claims - HIPAA ANSI v5010 Loop, Segment and Element:
      • Ordering Provider National Provider Identifier (NPI): Loop 2420E, NM1/DK, 09
      • Referring Provider National Provider Identifier (NPI): Loop 2420F, NM1/DN, 09
• Eligible providers may be reimbursed for a single transportation fee for each trip made to a particular location
  • If only one patient is served, submit HCPCS code R0070, since this code reflects only one patient seen
    • HCPCS code R0070 - Transportation of Portable X-ray Equipment and Personnel to Home or Nursing Home, Per Trip to Facility or Location, One Patient Seen
  • If more than one patient is served, submit HCPCS code R0075, since this code reflects multiple patients being served
    • HCPCS code R0075 - Transportation of Portable X-ray Equipment and Personnel to Home or Nursing Home, Per Trip to Facility or Location, More than One Patient Seen, Per Patient
  • If a provider submits more than one transportation fee per day, documentation must indicate that more than one trip was made to the location
    • For claims submitted electronically, this information must appear in the documentation record (NTE-02)
    • If paper claims are submitted, the documentation must be submitted as an attachment to the CMS-1500 claim form
    • If the information is not provided, the services will be denied
    • The units field for HCPCS code R0075 must be reported as one except in extremely unusual cases. Use HCPCS modifiers to indicate the number of patients served. The HCPCS modifiers are:
      • UN - Two patients served
      • UP - Three patients served
      • UQ - Four patients served
      • UR - Five patients served
      • US - Six patients or more served (quantity billed must reflect one)
• The units field may not be used to report the number of patients served during a single trip. Specifically, the units field must reflect the number of services that the specific beneficiary received, not the number of services received by other beneficiaries.
• No transportation charge is payable unless the portable X-ray equipment used was actually transported to the location where the X-ray was taken. Medicare will not allow a transportation charge when the X-ray equipment is stored in a nursing home for use as needed.
  • The Medicare Administrative Contractor (MAC) will pay a set-up component for each radiologic procedure (other than retakes of the same procedure) during both single patient and multiple patient trips
    • HCPCS code Q0092 - Set up portable X-ray equipment