Radiology & Radiation Therapy Copayment Tip Sheet

Effective with dates of service Jan. 1, 2014
Applicable to Commercial & Medicare Advantage (Excludes Self Funded)
Type of Service Contracts Without Radiology Differential Copayment Contracts With Radiology Differential Copayment
Number of Copayments to charge the patient The Patient's Cost Share Responsibility Number of Copayments to charge the patient The Patient's Cost Share Responsibility
Diagnostic X-ray & Advanced Radiology One Radiology Two Routine & Advanced Radiology
Diagnostic Test & E&M One E&M One E&M
Two Diagnostic X-ray One Radiology One Radiology
Two Advanced Radiology One Radiology One Advanced Radiology
Diagnostic Radiology & Diagnostic Test One Higher of the two services One Higher of the two services
Advanced Radiology & Diagnostic Test One Higher of the two services One Higher of the two services
Diagnostic X-ray & E&M * Two Radiology & E&M Two Radiology & E&M
Advanced Radiology & E&M Two Radiology & E&M Two Advanced Radiology & E&M
Diagnostic X-ray & Advanced Radiology & E&M Two Radiology & E&M Three Radiology & Advanced Radiology & E&M
Radiology Non-guidance & E&M & Procedure Two Procedure & Radiology Two Procedure & Radiology
Radiology Guidance & Procedure (Inj.) in Office or Outpt. Setting (non-ambulatory surgery setting/POS24) One Procedure One Procedure
Diagnostic X-ray & Diagnostic Test & E&M Two Radiology & E&M Two Radiology & E&M
Advanced Radiology & Diagnostic Test & E&M Two Radiology & E&M Two Advanced Radiology & E&M
Three Diagnostic X-ray One Radiology One Radiology
Two Advanced Radiology One Radiology One Advanced Radiology
Advanced Guidance & Radiation Therapy One Radiation Therapy One Radiation Therapy
Radiation Therapy & E&M Two Radiation Therapy & E&M Two Radiation Therapy & E&M
Diagnostic X-ray & Jcode One Radiology One Radiology
Advanced Radiology & Jcode*** One Radiology One Advanced Radiology
Notes:
- Copayments are per provider, per Date of Service.
* Evaluation & Management