The examples in this section are to help providers bill radiology procedures on the CMS-1500 claim form. Refer to the Radiology: Diagnostic section of this manual for detailed policy information. Refer to the CMS-1500 Completion section of this manual for instructions to complete claim fields not explained in the following example. For additional claim preparation information, refer to the Forms: Legibility and Completion Standards section of this manual.
Billing Tips: When completing claims, do not enter the decimal points in ICD-9-CM codes or dollar amounts. If requested information does not fit neatly in the Reserved for Local Use field (Box 19) of the claim, type it on an 8½ x 11-inch sheet of paper and attach it to the claim.
Chest X-ray Figure 1. Chest X-ray.
This is an example only. Please adapt to your billing situation.
In this example, CPT-4 code 71020 (radiologic examination, chest; two views, frontal and lateral) is billed with modifier ZS (indicating both professional and technical components were provided) in the Procedures, Services or Supplies field (Box 24D).
In the Date(s) of Service field (Box 24A), the date of the office visit, June 7, 2007 is entered on claim line 1 as 060707. Enter Place of Service code 11 (office) in Box 24B.
Enter the referring provider name in the Name of Referring Provider or Other Source field (Box 17) and the referring provider’s NPI in
Box 17B. Enter the rendering provider’s information in Service Facility Location Information field (Box 32) and the NPI in Box 32A.
Box 17B. Enter the rendering provider’s information in Service Facility Location Information field (Box 32) and the NPI in Box 32A.
Enter the usual and customary charges in the Charges field
(Box 24F). Enter a 1 in the Days or Units field (Box 24G) for code 71020.
(Box 24F). Enter a 1 in the Days or Units field (Box 24G) for code 71020.
Bilateral Radiography Billed Figure 2. Bilateral radiography billed with unilateral code.
with Unilateral Codes
This is an example only. Please adapt to your billing situation.
In this case a physician orders a bilateral eye socket X-ray. This claim example illustrates the billing of a bilateral radiographic procedure with a unilateral code.
In the Reserved for Local Use field (Box 19), enter a statement declaring a bilateral procedure was done but was billed with a unilateral code.
In this example, CPT-4 code 70190 (radiologic examination; optic foramina) is billed with modifier TC (technical component) in the Procedures, Services or Supplies field (Box 24D).
In the Date(s) of Service field (Box 24A), the date of the office visit, June 7, 2007 is entered on claim line 1 as 060707. Enter Place of Service code 11 (office) in Box 24B.
Enter the referring provider name in the Name of Referring Provider or Other Source field (Box 17) and the referring provider’s NPI in
Box 17B. Enter the rendering provider’s information in Service Facility Location Information field (Box 32) and the NPI in Box 32A.
Box 17B. Enter the rendering provider’s information in Service Facility Location Information field (Box 32) and the NPI in Box 32A.
Enter the usual and customary charges in the Charges field
(Box 24F). Enter a 2 in the Days or Units field (Box 24G) for code 70190. This number indicates the procedure is bilateral. Enter in the Reserved for Local Use field (Box 19) that the procedure was performed bilaterally.
(Box 24F). Enter a 2 in the Days or Units field (Box 24G) for code 70190. This number indicates the procedure is bilateral. Enter in the Reserved for Local Use field (Box 19) that the procedure was performed bilaterally.
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Many insurance carriers require pre certification for diagnostic procedures. It is the responsibility of the physician that referred you to Kerner Radiology to ensure the diagnostic test they ordered is approved by your plan.
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