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Pulmonology Coding Alert

Dont Rush to Bill for X-ray Interpretations You Might Land Your Practice in Hot Water

Published on Fri Aug 01, 2003

When billing for x-ray interpretations, some pulmonology coders follow the "first come, first served" philosophy for quick reimbursement they rush to submit claims first for x-ray interpretations to capture new revenue. But coding experts warn that you should avoid this practice like the plague.

Here's a familiar scenario: A primary-care provider (PCP) sends a patient complaining of fever and chest pain to a radiologist, who takes x-rays (71010, Radiologic examination, chest; single view, frontal) and diagnoses the ailment as acute bronchitis (466.x). The PCP then sends the patient to your pulmonologist. But the patient brought the x-ray film, not the radiologist's written report, which describes his or her diagnosis. So, without a report, can your pulmonologist now bill for his interpretation of the film?

No, says Felecia Bernstein, CPC, EMT, a coding and reimbursement specialist and president of the Monmouth Chapter of the American Academy of Professional Coders in Deal, N.J. The pulmonologist should not bill for an interpretation of the results if a patient's PCP sent him or her to a radiologist, who then made the diagnosis before sending the patient to the pulmonologist for treatment. The pulmonologist shouldn't bill for a reading, she says.

Indeed, CPT specifies that "The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M service." In other words, the radiologist performs and bills for an interpretation and then forwards the interpretative report to the PCP. Medicare and private carriers will pay only once for separately billed diagnostic services.

Report a Higher-Level E/M

Most radiologists write reports for every patient, coding experts say. When a patient presents to a pulmonologist with only the x-ray films in hand, the patient probably forgot to bring the report or the patient's PCP failed to forward the report to the pulmonologist.

If your pulmonologist wants compensation for attending to a patient who presents with films, he or she should document in the progress notes any extra work that could allow you to code for a higher E/M level, says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

For instance, a woman with a cough (786.2) and shortness of breath (786.05) presents to your pulmonologist, but she brings only the x-ray film not the radiologist's written report. The pulmonologist requests the patient's missing report, interprets the films as acute bronchitis (466.0), and develops a treatment plan. Because your physician ordered the records, he or she can receive credit for this in the "amount and/or complexity of data ordered/reviewed" category of medical decision-making. In this point system, the pulmonologist will receive one point for the decision to obtain records and two points for the independent visualization of the films. Ordering records satisfies one of the two categories required for reporting moderate-complexity decision-making a key component for 99204 (Office or other outpatient visit ...).

In certain cases, your pulmonologist can append modifier -26 (Professional component) to radiological services (71010-71555) for an interpretation of x-ray film. But if you bill for the interpretation, you cannot count the interpretation in your complexity of medical decision-making, coding experts say. Berman and other coding experts offer the following recommendations for when you can legitimately bill modifier -26.

 
  •  The pulmonologist owns an x-ray machine, takes films, interprets the results and issues a report without the involvement of a radiologist. For example, your pulmonologist takes an x-ray of a patient who complains of shortness of breath (786.05) and chest pains (786.5x). Your physician interprets the film as asthma and develops a treatment plan. You could legitimately report 71010-26.
     
  •  The radiologist "invites" the pulmonologist to provide a second diagnosis. For example, a PCP sends a patient suffering from chest pain (786.5x) and coughing up blood (786.3) to a radiologist. But after the radiologist takes the x-rays, he cannot determine a diagnosis, so he refers the patient to a pulmonologist to inspect the film results. A radiologist is unlikely to request a second diagnosis, however, because it requires that the pulmonologist have a greater level of expertise than the radiologist. Pulmonologists typically do not possess the greater level of expertise, Berman says.
     
  •  The radiologist didn't complete a diagnostic report. If a radiologist saw the patient but didn't write a diagnostic report, the pulmonologist can bill for his review of the film results, coding experts say. Poor communication or misunderstandings could lead to conflicts with the radiologist, however. So make sure the radiologist didn't write a report, and the PCP forgot to forward your pulmonologist a copy. Also, if a report is missing, your physician might want to confer with the radiologist to avoid any conflict between the services, experts say.

    • Report Modifier -26 With Caution

    In any case, a pulmonologist who bills the professional component for an x-ray interpretation is taking "a very high risk" of facing fines, fraud charges or a lawsuit, Berman says. With the medical malpractice climate today, the small amount of payment isn't worth the risk, he adds.

    Make sure to check if your local insurer allows pulmonologists to bill for any radiological services. Some carriers, such as Independent Blue Cross Blue Shield of Pennsylvania, will pay only radiologists for 70000-series codes. Also, all insurers maintain profiles of physicians. And if your pulmonologist bills 71010-26 several times, and he is not credentialed in radiological services, your physician's profile will become skewed which could lead to fines or fraud charges, coding experts warn.

    Pulmonologists who feel that they have met the Medicare guidelines to bill for diagnostic services still have to follow specific criteria to justify appending modifier -26 to a radiological code. Without the modifier, using 71010, for example, signifies that the pulmonologist owns the equipment.

    Before you report 71010-26, consider the following criteria, coding experts say:

     1. The physician must be the one who initially reads and interprets the results.

     2. When the pulmonologist makes the pneumonia diagnosis, he must develop a treatment plan.

     3. The pulmonologist must write a radiological report similar to what is required of a radiologist. Carriers previously required that physicians write and submit unattached and distinct radiological reports. But now Medicare carriers accept reports with some indication, such as a subhead, that the radiological interpretation will follow.

    For example, if the pulmonologist provides a consultation in addition to the radiological interpretation, the radiological report can be included in the consultation report, or if in a hospital environment, the progress notes, experts say. If an auditor reviews your report, you will need to submit the entire consultation (consult included). Your entire service will come under scrutiny, not just the portion that was requested.

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