Pediatric Coding Alert

Question: How should we report a scenario in which the physician did not take x-rays but interpreted them?

Missouri Subscriber

Answer: Report the same codes you would if the physician had taken the x-rays himself, but make sure you append modifier -26 (Professional component) to the x-ray code.

For example, if the pediatrician interprets two views of a patient's wrist, but someone else performed the x-ray, you should report code 73100 (Radiologic examination, wrist; two views) with modifier -26 attached. The modifier tells the payer that you are billing for the interpretation of the x-ray, but not for taking the picture. (When you append modifier -26, the payer deducts the technical component from the payout on 73100.)

The trouble starts when, in many instances, two entities bill for professional services -- usually, a radiologist and the pediatrician. Although CMS mandates that it will only pay the physician providing the reading at the same time as the patient's care, many private insurance companies (incorrectly) only pay the first claim they receive, or pay for the interpretation of a board-certified radiologist.

Smart idea: Get those modifier -26 claims out the door as soon as possible to ensure maximum ethical reimbursement -- but keep in mind that this can cause some significant problems with your radiologist colleagues.