26 modifier for radiology with E&M

mykajens

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One of our locations uses a hospital for x-rays but our physicians read. We have been billing a -26 modifier with the x-rays that allow technical and professional components. We've gotten denials when billed with an E&M code, stating "mutually exclusive to the primary procedure code". We have asked the hospital if they're billing with -TC modifier and they are. Any ideas?
 

mykajens

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We've received denials from Aetna, medicaid products, BCBS...one of the denials states "per AMA Principles of CPT Coding Guidelines"
 

Pam Brooks

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E&M and diagnostics are not mutually exxclusive, and don't hit a CCI edit.

Here's the question: are the hospital's radiologists also reading these Xrays, or do your providers have a contract with the hospital to exclusively do so? If their radiologists are reading the xrays, and they're billing for both the professional and technical component on the UB, then your docs cannot also bill for the read. The read is going to require a report go into the hospital's medical record, so if your docs are billing the read with the -26 for their own purposes alone, you are unbundling and are not entitled to that payment. Just becasue you read an xray doesn't mean you can bill for it. you can include that read as a data point for calculating medical decsision making for your MDM.
If you do have a contract to be the reading provider for those imaging services, then this sounds like a payer edit.
 

mykajens

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E&M and diagnostics are not mutually exxclusive, and don't hit a CCI edit.

Here's the question: are the hospital's radiologists also reading these Xrays, or do your providers have a contract with the hospital to exclusively do so? If their radiologists are reading the xrays, and they're billing for both the professional and technical component on the UB, then your docs cannot also bill for the read. The read is going to require a report go into the hospital's medical record, so if your docs are billing the read with the -26 for their own purposes alone, you are unbundling and are not entitled to that payment. Just becasue you read an xray doesn't mean you can bill for it. you can include that read as a data point for calculating medical decsision making for your MDM.
If you do have a contract to be the reading provider for those imaging services, then this sounds like a payer edit.
We do have a contract with the hospital for them to bill the technical component and we bill the professional component. We purchased the AMA Principles of CPT Coding and can't find where it specifically states it can't be billed. Thanks!
 
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