ED Coding and Reimbursement Alert

Remember to use modifiers when necessary to denote medically necessary repeat tests.

If your ED has suddenly seen payments drop for repeat chest x-rays and EKGs, you aren't alone. Knowing exactly why you faced the denial is important, because some such issues can be remedied with the simple use of modifiers.

Background: Duplicate denials for chest x-rays or EKGs have been identified as a common error by several Medicare Administrative Contractors (MACs). For example, according to Palmetto GBA's recent posting on the issue, denials for these services are climbing rapidly because providers don't appropriately bill the repeat services. The instructions for reporting legitimate duplicate claims are as follows, the MAC says on its website:

• Submit multiple 'identical' services on the same claim. Use the quantity field to reflect the number of services. If the services cannot be submitted on a single claim, useCPT^® modifier 76 and specify the exact times of each service.
• On electronic claims, use the documentation record to specify the exact times that each diagnostic service (e.g., chest x-ray, EKG, etc.) was done.
• On electronic claims, use the documentation record to explain why more than one diagnostic service was done on the same date by the same provider.
• Attachments (e.g., signed radiology reports, signed EKG reports, etc.) for paper claims must identify the patient's name, Medicare number, date of service and other pertinent information (e.g., times):
• On appeal, signed medical records (e.g., radiology reports, EKG reports, etc.) may be sent as evidence to show why more than one diagnostic service was billed on the same date by same or similar providers from the same group.

Noridian Healthcare Solutions, another Part B provider, offers the following example: "Provider performed two chest x-rays on same day. Billed the chest x-ray code with date of service 10/12/16 twice. One claim submitted on 10/20/16; another claim submitted on 10/21/16. Both claims denied as duplicate. Both claims billed for same patient, same provider, same date of service, same charge, same CPT^® code, and same units without modifier."

In reality, Noridian says, if both services were medically necessary and distinct, 71045 (Radiologic examination, chest; single view) should be billed on the first line of service with no modifier, and the second line should list 71045-76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional).

Get to Know Modifiers 76, 77

Modifiers 76 and 77 (Repeat Procedure by Another Physician or Other Qualified Health Care Professional) help payers determine that the services are not duplicates, and the documentation needs to show that the repeat procedure was medically necessary. The modifiers are different in that modifier 76 refers to a repeat service by the same physician, while modifier 77 covers services performed by another physician.

The example above demonstrated how to report modifier 76, so the following example will show you when modifier 77 applies.

Example: A patient presents to the ED complaining of chest pains and numbness in her right arm. The ED physician orders an EKG and writes the interpretation for it. He finds no abnormalities. The physician's shift ends and another physician sees the patient, who is still complaining of chest pains. He reads the EKG and notices an abnormality so he writes another report. Both doctors bill 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).

You're unlikely to see payment for the second interpretation unless you have strong documentation supporting medical necessity. For instance, if an individual, extraordinary case requires the expertise of someone with more specialized training than the first physician can provide, you could try to argue for the additional payment, assuming the second physician writes a full report as well. Payers may request the use of modifier 77 (Repeat procedure or services by another physician or other qualified health care professional) in that situation.

Consider this quote from Medicare Claims Processing Manual, Chapter 13, Section 100.1, about tests in emergency departments: "Generally, carriers must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier '77') only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure."

Keep in mind: Medicare's national fee for 93010 is less than $9. If payment for the over-read will require an appeal, you may want to weigh the cost in time and effort against the expected reimbursement.

Resource: To read Palmetto's report on repeat chest x-ray and EKG denials, visit https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM Part B~Browse by Topic~Denial Resolution~8EELKX8677?open.