Wiki Ordering and interpreting xray-double dipping????

[Ash82]

If my physician orders an xray(1 point), performs and interprets the xray(2 points), can he get credit for three points in the MDM? I have read in several different places that this is considered double dipping if he gets paid the professional fee for interpretation as well as getting the two points in the MDM for reading it. If anyone has anything from CMS to clarify this, I would really appreciate it.

 

[jdibble]

If my physician orders an xray(1 point), performs and interprets the xray(2 points), can he get credit for three points in the MDM? I have read in several different places that this is considered double dipping if he gets paid the professional fee for interpretation as well as getting the two points in the MDM for reading it. If anyone has anything from CMS to clarify this, I would really appreciate it.

First I would have to ask you who is your MAC, as that could make a difference? I have found that the answer to this is, as usual, one of those gray areas of E/M coding. I reached out to Novitas and First Coast for an answer on this as I had someone who was providing a seminar for my doctors who stated the doctors would get credit for it all! The following was the response I received from Novitas:

Dear Jodi Dibble,

This email is in response to your inquiry we received on January 6, 2015. We apologize for the delay in this response. Novitas Solutions only give 2 points for independent visualization because those 2 points include the x-ray, EKG, etc. that is being visualized by the provider. We don’t give credit for 3 points because that would be double dipping. If the physician only reads the radiologist report without independent visualization, then it is 1 point. If the provider is billing separately for the interpretation of the test, then that same physician will not get credit for independent visualization in the amount and complexity of data grid because that also would be double dipping. He is already getting paid for the interpretation so we won’t give credit because that would give him a higher score in that section, which would be double dipping for higher reimbursement for the E/M code.

There is also a contractor decision on our website that addresses the providers question as well at: http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004948 as follows:

“If a provider is billing for the professional component of a test in the radiology and/or medicine section of the Current Procedural Terminology (CPT) Manual and an Evaluation & Management (E/M) procedure code on the same date of service, should that physician receive credit under the Independent Visualization of an image, specimen or tracing component in the Amount and /or Complexity of Data Reviewed Section of the Medical Decision Making key component of an E/M?
If the provider is billing separately for the interpretation of a test in the radiology and/or medicine section of the CPT, then that same physician should not take credit for the independent visualization of that test in the Amount and /or Complexity of Data Reviewed Section of the Medical Decision Making key component of an E/M.
The 1995 E/M Documentation Guidelines address this issue on page 13 and state that, "The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented."

If the provider is not billing separately for the interpretation of the test or the test was performed by another provider and that physician is independently visualizing the test, then the provider may take credit for the independent visualization of that test in the Amount and /or Complexity of Data Reviewed Section of the Medical Decision Making key component of an E/M.”

Thank you for your inquiry.

Sincerely,

Dezirae Yingling
Novitas Solutions, Inc.
Provider Contact Center:
Provider (877) 235-8073 Provider TeleTypewriter (TTY) (877) 235-8051
Beneficiary (800) 633-4227 or TTY (877) 486-2048

Then I got this response from First Coast in Florida:

Dear Ms. Dibble:

This e-mail is being sent in response to your inquiry received in our office on November 3, 2014, attached below. Your request pertains to clarification of medical decision making (MDM).

In researching your request, contact was made with our Comprehensive Error Rate Testing (CERT) Department. They have indicated that you can obtain points for the order and the independent viewing. They have also confirmed that if the same doctor is billing for the EKG and interpretation, he can also obtain points for the data. They have also agreed that if the provider owns the machine that performs the EKG and only bills for the EKG report that he can obtain points for the order and the individual review. However, there must be clear documentation that the physician ordered and independently interpreted the EKG. It is not sufficient to use the printed interpretation on the EKG printout.

I hope the information I have provided is helpful. If you have any questions regarding this inquiry, you may contact me directly at 904-791-6147. If you have general questions, you should contact a member of our Provider Contact Center (PCC) at 866-454-9007.
Sincerely,


Maureen Pickering
Provider Relations Research Specialist (PRRS)
Medicare Customer Service Center

So, it would depend on which MAC you have - they may have a completely different answer!! I, myself, go with Novitas and do not give them any credit for data points if they are billing for the x-rays as I feel that is double-dipping.

Any other ideas out there?

 

[thomas7331]

My personal opinion, based on discussions I've had with providers, is that this is not double dipping. Though there may be some overlap of the work, these are two different things. Billing for the interpretation is a fee for the provider's skill in reading the image, and for the preparation of a formal report for the patient's medical record. The data section of the MDM not interpretation and report, it is taking the data that is available and putting it in the context of the patient's clinical presentation at the time of the visit, what physicians sometimes refer to as 'clinical correlation'. That said, it seems to me that payers these days are (thankfully) less concerned with how many points are counted and boxes are checked than they are with making sure the level of the visit is consistent with the nature of the patient's presenting problem and with the quality of the care, so I wouldn't lose sight of the bigger picture over this kind of technicality. I'd also be interested in hearing others' thoughts.

 

[thomas7331]

And very interesting to read these payers' responses, Joy; thank you for sharing! This provides a lot of insight into how payers do their audits, which is not always transparent.

 

[jdibble]

My personal opinion, based on discussions I've had with providers, is that this is not double dipping. Though there may be some overlap of the work, these are two different things. Billing for the interpretation is a fee for the provider's skill in reading the image, and for the preparation of a formal report for the patient's medical record. The data section of the MDM not interpretation and report, it is taking the data that is available and putting it in the context of the patient's clinical presentation at the time of the visit, what physicians sometimes refer to as 'clinical correlation'. That said, it seems to me that payers these days are (thankfully) less concerned with how many points are counted and boxes are checked than they are with making sure the level of the visit is consistent with the nature of the patient's presenting problem and with the quality of the care, so I wouldn't lose sight of the bigger picture over this kind of technicality. I'd also be interested in hearing others' thoughts.

I do agree with some of what you are saying. I would give my providers the 1 point credit for ordering the test, however if they are charging for the interpretation, I do not give them the 2 points for "Independent visualization of image, tracing or specimen itself". I know I had read somewhere (and of course I don't have that source at this moment) that this category is for those situations when the provider is visualizing the item directly (rather than just reviewing the report) when another provider is the one who is or has performed the interpretation. So, if the provider is the one performing the interpretation, he would be double dipping as he is not also doing a second read of the image that he already documented. I don't think he is doing any further work as he has already come up with his clinical correlation when he did the interp. Unless he doesn't agree with himself!

 

[bolsen01]

Ordering and Interpreting xray-double dipping?

Jodi, I agree with you. When our orthopedic physician perform an x-ray in their office, (they own the equipment), I give them 1 point for the decision to order the x-ray. They do NOT get teh add'l 2 points for viewing the image. They will bill for the x-ray, so they don't get credit for viewing/interpreting the image twice! The appropriate use of those add'l 2 points (when the physician is NOT billing for the x-ray, etc. is as follows: MDM section, Amt and/or Complexity of Data Reviewed requires that the physician document his interpretation of what he just looked at. Our MAC is Novitas. See Frequently Asked Questions: Evaluation and Management Services, Question #20,

http://www.novitas-solutions.com/we...state=109vsf9p8x_17&_afrLoop=672662240204324#!

20. If I personally review a film, e.g. x-ray, electrocardiogram (EKG) in my office, will I receive 2 points on the E/M score sheet?
Yes, you may get two points for independent visualization of an image, tracing or specimen on the E/M score sheet in the Amount and/or Complexity of Data Reviewed section under the Medical Decision Making key component. The medical record documentation must clearly indicate that the physician/qualified NPP personally (independently) visualized and performed the interpretation of the image; tracing or specimen and that he/she did not simply read/review a report from another physician/qualified NPP.

Hope this helps.