Mod -26 included in E&M per NCCI edit?

caskln1

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Please help me! We have doctors that see patients outside of our main clinic and order x-rays. The facility bills the x-ray only with a modifier TC, we bill the appropriate E&M with a modifier 26 since our doctors "read & interpret" the x-ray, however we have been getting denials saying that the "read" is part of the E&M per NCCI edit....... Is this true and where can I find this information in writing?
 

aaron.lucas

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if the doctor that is reading the x-ray doesnt actually write the radiology report, then they can't bill for the professional component. only the individual who interprets the films and writes up a formal report of the findings can bill for the -26. I do code review for a 3rd party admin company and I see a lot of doctors in the ER setting trying to bill for radiology with a -26 and all they're doing is looking at the films, then handing them off to the radiologist who actually does the report and all, and that just isnt correct. plus not sure you meant it to sound like this, but you cant use -26 on an E/M as there is no "professional component" for those services. Hope this helps :)
 

jmcpolin

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I have the same problem with some Urgent care docs where they order and xray and do not even mention the findings or what views and they are trying to bill for the xray. They are new to us and getting them to understand that they have to dictate a separate radiology report is not going to be fun lol
 

caskln1

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-26 on the x-ray code

if the doctor that is reading the x-ray doesnt actually write the radiology report, then they can't bill for the professional component. only the individual who interprets the films and writes up a formal report of the findings can bill for the -26. I do code review for a 3rd party admin company and I see a lot of doctors in the ER setting trying to bill for radiology with a -26 and all they're doing is looking at the films, then handing them off to the radiologist who actually does the report and all, and that just isnt correct. plus not sure you meant it to sound like this, but you cant use -26 on an E/M as there is no "professional component" for those services. Hope this helps :)
Sorry about the confusion! No we don't put the modifier 26 on the E&M code, it's placed on the appropriate radiology cpt code. Our doctors do write up a report on their findings and the facility bills out the TC. So that's why I am confused as to why some carriers are saying that the professional component is included in the E&M code per NCCI edit.
 

aaron.lucas

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yeah that doesn't make any sense, I mean reviewing films is part of the MDM, but if they're doing the actual interpretation and report then that should be separately reimbursable. the only one that wouldnt be is the x-ray consult, I think 76140, but that represents just reviewing films that were interpreted elsewhere, which like I said is included in the MDM.
 
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