Radiology Coding Alert

Be extra cautious with auto-populating POS codes.

You’ll find no shortage of coding and billing guidelines to keep track of so long as you know where to look. One of the more comprehensive sources for radiological coding guidelines comes from Chapter 13 of the Medicare Claims Processing Manual. This chapter, titled Radiology Services and Other Diagnostic Procedures, goes into such extensive detail that you may still be coming across new sets of rules and policies you hadn’t previously heard of.

Today, you’re going to revisit Chapter 13 of the Medicare Claims Processing Manual to have a look at a few sets of guidelines that may have flown under the radar alongside other guidelines that may have a more substantial impact on day-to-day practices.

Check out some of these lesser-known policies to take your radiology coding knowledge to the next level.

Know What’s Required for Global Billing

In this first guideline, you’ll see how CMS lays out some clear-cut rules on what’s allowed for global billing. Have a look at the following policy:

• “Billing globally for services that are split into PC and TC components is only possible when the TC and the physician who provides the PC of the diagnostic service are furnished by the same physician or supplier entity and the PC and TC components are furnished within the same Medicare physician fee schedule (MPFS) payment locality. Merely applying the same POS code to the PC as that of the TC (as described in “A” above) does not permit global billing for any diagnostic procedure.”

This means that you need more than just a mutual place of service (POS) code in order to bill for a service globally. Both the professional component (PC) and technical component (TC) must be performed within the same Medicare Physician Fee Schedule (MPFS) payment locality. In other words, the national provider identification (NPI) must be the same for billing of each respective component. If the physician bills under a separate NPI for the PC, then the respective services must be submitted with modifiers 26 (Professional Component) and TC (Technical Component).

Use Modifier 52 for One Component of S&I Services

If you’re working on a case involving radiologic supervision and interpretation (RS&I), you’ll want to know what to do if the documentation only supports the supervision or interpretation component, but not both. CMS explains it with a helpful cardiology example:

• “In situations in which a cardiologist, for example, bills for the supervision (the “S”) of the S&I code, and a radiologist bills for the interpretation (the “I”) of the code, both physicians should use a “-52” modifier indicating a reduced service, e.g., only one of supervision and/or interpretation. Payment for the fragmented S&I code is no more than if a single physician furnished both aspects of the procedure.”

In considering a scenario when one radiologist supervises an RS&I and another interprets, each will append modifier 52 (Reduced Services) to their claims. The compensation will be reduced accordingly, as well.

Bill Accordingly for Unusual and Infrequent Locations

You may come across a situation where a provider interprets a service from a location outside of his or her usual setting. Since the billing process requires documentation of an address and ZIP code of the location the service was interpreted, you may wonder what you’re supposed to do differently when the service is interpreted in a separate location. In these cases, you’ve got to take a few extra measures in the billing process to ensure the claim gets submitted properly. Have a look at this lesser-known guideline:

• “If the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional interpretation is determined based on the Medicare enrolled location where the interpreting physician most commonly practices. The address and ZIP code of this practice location is entered using the ASC X12 837 profes­sional claim format or in Item 32 on the paper claim Form CMS 1500.”

Fortunately, CMS policy makes it easy on billers of a provider who routinely performs services outside of his or her usual office setting. In these cases, you’ll submit the service using the address and ZIP code of the location in which the provider is most active.

Don’t Fall Victim to POS Code Misconceptions

Lastly, if you’ve ever had questions about how to bill for place of service (POS) codes for professional services, look no further. CMS spells it out clearly in this guideline:

• “The appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the TC service. If the interpretation is performed in the physician’s office and the patient received the TC service in the provider-based outpatient hospital setting, the physician assigns POS code 22, for On Campus-Outpatient Hospital, or POS 19, for Off Campus-Outpatient Hospital, on the claim for the interpretation or PC.”

These guidelines illustrate that you should choose the POS code based on where the TC portion of the service was rendered, not the PC portion of the service. This goes against a long-held misconception within the radiology specialty that POS refers exclusively to the setting in which the physician interprets the imaging.

Depending on what coding software you use, this means you want to be cautious and vigilant in checking that the appropriate POS is appended to the claim. “Your POS options will depend on what physician setting you’re coding for,” says Lindsay Della Vella, COC, CMCS, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “Most traditionally, hospital coders may vary between POS codes for outpatient, emergency room [ER], and inpatient. However, if the POS code auto-populates into your coding software, you should always check to make sure the POS code matches the setting from the patient records,” advises Della Vella.