Wiki Er e/m and rad billing

[pmaccallum]

I work for radiology diagnostic practice at a hospital. We have denials from Medicare for "other physician already paid". The ER physicians are billing 99284 and 99285 plus the professinal component of our radiology services as if they are writing the reports. They are submitting these claims to Medicare in 6 days (1 day before us). ex.
73610/26LT and 99284
We have over 400 claims denied because the same ER physician group is billing one day before us.
If they are asked to provide a radiology report as they are billing for, they cannot becuase that is not their taxonomy.
Can the ER physicians code for the report and the E/M interpretation to resolve immediate patient complaint?
If they are allowed, can we append another modifier besides 26 and 77 to get medicare to pay the claims w/o coming back as duplicate?

Thank you,

 

[mitchellde]

If the ER physician is not providing a radiology interpretation report then they cannot bill with the 26 modifier. Their preliminary read is part of the E&M. You should contact the hospital coding department manager to complain and get this to stop. Also appeal every one of them and include in the appeal the copy of you official interpretation. Ask the ER coder or department for a copy of one of their interpretations. And submit that in your appeal as well and request the payer make the determination as to which provider performed the official interpretation.

 

[alinton01]

ER E&M Radiology

Unfortunately, it seems the two entities need to sit down and have a discussion. Obviously the radiologist that is doing the full interpretation and report should be billing the professional component. Medicare is only going to pay for one interpretation of the x-ray. Going on the assumption that the Radiologist is doing the full interpretation and the ER doctor is not: The Emergency Dept physician that is reviewing the film (not doing the interpretation) to make his medical decision should include the work value for this when he decides his level of E&M service to bill. This is accounted for in the Amount and/or Complexity of Data Reviewed-Independent visualization of image, tracing or specimen itself, which would give him 2 points in the amount/complexity of data points in the MDM component of the E&M. Some education would need to be done with the Emergency physicians. The Administration staff of the Radiologists would likely need to speak with the Administration staff from the ER first. You could appeal (redetermination request) however this could open up the ER docs to problems so I would speak to them first to give them an opportunity to correct their problem. You are working in the same facility, no reason you can't find a solution to make it work-just needs some communication. Just my 2 cents!

 

[pmaccallum]

Thank you! That was very helpful. I called Medicare today on an appeal I had done already for one claim and it was denied. Stating that no matter what doctor billed it once it was paid once it will not be paid again. I explained that the wrong doctor billed it they said to appeal again. I might have to contact the Regional MAC on this one.