Pulmonology Coding Alert

Learn when to report modifiers -26 and -77 with 71010

Even if your physician orders and interprets a chest x-ray or other diagnostic test, you shouldn't bill these diagnostic services separately from your E/M services. But you can consider the test a factor in the pulmonologist's medical decision-making when you choose the E/M level.

Tip #1: Avoid Double-Billing

Before billing for any diagnostic test interpretations that a technician at  another facility completed, be sure that another physician hasn't already laid claim to the service.

A possible scenario: The physician suspects that a patient has pneumonia, and he sends her to the hospital for a chest x-ray (71010, Radiologic examination, chest; single view, frontal).

Why you might not be able to bill the interpretation: In the hospital, a facility radiologist or other physician may interpret all ordered tests as a matter of policy. And if one physician interprets a test and provides a report outlining the result, no other physician can bill for the same service. This would constitute "double-billing," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., in Brick, N.J., and a member of the AAPC National Advisory Board.

Tip #2: Disagreement May Warrant Rebill

What if your physician disagrees and feels that he should bill for his interpretation? Many coders and physicians believe that if the ordering physician disagrees with the radiologist's interpretation, and if the ordering physician writes his own full report of the test, his interpretations counts as a correctly formatted report with a conflicting outcome.

Indeed, the Medicare Carriers Manual instructs that "practices deserve pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient." Bottom line: When you have the documentation to back it up, you should submit your claim with modifier -26 (Professional component) appended to the appropriate x-ray code.

Don't miss: If the technician who performs the diagnostic service also rereads the diagnostic test on the same date that the original physician performed his interpretation, you should also append modifier -77 (Repeat procedure by another physician) to the diagnostic service code.

But don't expect hassle-free payment from your insurer in this case. You should bill for your physician's reread only if his dictation supports it, coding experts say.

Example: If the original interpretation reveals the radiologist's opinion that the patient's chest x-ray is normal, but your physician sees a slight spot on the x-ray that may indicate pneumonia, you should send in copies of both interpretations and highlight the differences, along with your claim.

Remember: Your physician's documentation must demonstrate medical necessity of the service as well as professional interpretation. 

As Medicare explains, "a notation in the medical records saying 'fx-tibia' or 'EKG-normal' would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An 'interpretation and report' should address the findings, relevant clinical issues, and comparative data (when available)."

Conclusion: Always check and double-check your documentation on details for the results of the procedures, specific clinical issues including details on presenting symptoms and causes, and any cases to compare this case with when they are available.

Tip #3: Consider Other Rereads Toward E/M Level
 
Even when your physician is not eligible to bill for his interpretation, not all hope is lost.

Although the physician may not be able to claim separate reimbursement for test interpretation if another physician has already provided a report, the ordering physician can consider his own reading of the test results as a component of medical decision-making.

Opportunity: This component of medical decision-making may affect the level of any E/M service he provides, Cobuzzi says.

Explanation: The amount and/or complexity of data ordered or viewed includes medical records, diagnostic tests and other information that the physician must consider when examining the patient. This is a key component of medical decision-making, according to CPT guidelines. Both reading the interpretive report and  personally reviewing the images fall into this category, coding experts say.

Tip #4: Calculate E/M Points

You should include every detail of your physician's efforts, because if you don't, you may overlook an opportunity for reimbursement.

Example: If the physician documents that he reviewed the actual image, auditors can typically increase the "Amount and/or Complexity of Data Reviewed."

In the hospital, a physician attends to a patient who complains of chest pain, persistent coughing and shortness of breath. To check for pneumonia or other pulmonary problems, the physician orders an x-ray (for example, 71020, Radiologic examination, chest, two views, frontal and lateral).

The hospital radiologist provides the report, which then becomes part of the medical record that the physician must consider when making treatment decisions for the patient. The next day, the patient visits another physician's office and brings the films with her. The second physician reads the films and agrees with the hospital radiologist's interpretation.

Red flag: Avoid over-reading x-rays that patients bring into the office, says Jill Young, CPC, of Young Medical Consulting LLC, in East Lansing, Mich. Most insurance carriers will tell you they will not pay for readings brought into your practice by the patient because they consider the second interpretation a duplicate and not medically necessary, she says.

But, based on the key components of your physician's history, exam and medical decision-making (which includes consideration of the test results), the physician is justified in billing a level-four office visit (such as 99204 for new patients, 99214 for established patients).

If you question billing at such a high level for your E/M procedures, look to your documentation and you should have the documentation to justify your coding decision.

Editor's note: Look to "Remember to Use -26 for Interpretation and Report" at right for a quick tip on how to use modifier -26.