Ob-Gyn Coding Alert

In a time when ob/gyn practices need to identify every possible revenue source, many have been questioning whether or not they can legally bill for physician interpretation of lab and radiology results. The answer, says Becky Dawson, CPC, compliance education specialist for the Department of Surgery Corporation of Columbus, OH, is a cautious and qualified yes, but only in certain circumstances. The following explains when the ob/gyn can and cannot bill for lab or radiology interpretation.

According to the CPT

Prior to the listings for Evaluation and Management codes in the CPT, a section on E/M guidelines explains the ins and outs of E/M code use. The second-to-the-last paragraph under the heading of Levels of E/M Services was modified in CPT 1997 to clarify that the performance and/or interpretation of diagnostic tests and studies ordered during a patient encounter are not included in the levels of E/M services but billable separately. The CPT states: The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physicians interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with the modifier 26.

Practical Application

Before sharpening your pencil and getting ready to bill for all the interpretations your physicians are performing, Dawson warns that coders need to understand exactly what the CPT is saying. The only time the ordering physician should report an interpretation in addition to an E/M code is when two criteria are met: 1) the initial interpretation is done by the ordering physician and it is being used to treat the patient, and 2) a separately identifiable, signed report is written by the ordering/interpreting physician, citing the findings, Dawson says. There are no exceptions.

For example, if an ob patient presents with a problem that causes the obstetrician to suddenly send the patient down the street for an ultrasound and she returns with test in hand so the ob can interpret the test, billing for an interpretation may be possible if the above two conditions are met. If the ob does the interpretation first, he/she should be able to bill with the -26 modifier (professional component) and get paid, but be forewarned - if the radiologist also performs and bills for an interpretation, who gets paid often boils down to who gets their claim in first. Payers usually consider additional interpretations to be quality assurance checks and do not cover them. If the initial interpretation is done by the radiologist, then the ordering ob/gyn is not likely to be paid for a second interpretation. Further, when a physician provides an interpretation he or she must also prepare a separate and distinctly identifiable signed written report citing the findings of the test or study. If both these conditions are met, you would then use the appropriate CPT code along with the -26 modifier (professional component) unless of course a CPT exists for interpretation and report only.

While the above would also apply to the interpreting laboratory such as blood and urine studies, Dawson says it would be a rare circumstance in the ob/gyn setting when the ob/gyn would be the only physician (or first physician) interpreting laboratory results for tests performed elsewhere.

Using Interpretation for Higher Levels of E/M

When a radiologist or a pathologist has interpreted a test or diagnostic study, and you are unable to bill for your physicians interpretation, all is not lost. You may use the work a physician invests in reviewing those lab and radiology reports as credit toward a higher level of E/M coding. In our practice, the physicians spend time reviewing mammograms that have already been interpreted by a radiologist, says Dawson. But instead of billing for the professional component, they take credit for this review in their medical decision-making process, which may push them to a higher E/M level. This point is illustrated in the CPT section entitled Determine the Complexity of Medical Decision-Making including one of the three bullet points which reads: The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed.