Wiki Overread CPT code 76140 vs Original CPT code

[nperry@umc.edu]

I would be interested in knowing how your organization bills for Outside film interpretations. We have always billed CPT code 76140 and expected denials from Medicare. Some of our Radiologists went to a seminar and were advised that we should be billing for these under the regular CPT code of the area interpreted with an attached "26 & 77" modifiers. Our Compliance Dept has not allowed this in the past but now based on the below information states we should bill these as the regular original CPT codes. I would appreciate any feedback.

FAMILY PRACTICE MANAGMENT
Q. When we send X-ray films done in a family practice office to a radiologist for a second opinion after having billed the insurance for a global charge, what code should the radiologist use to be reimbursed?

A. Based on the information you’re provided, it seems the radiologist could use CPT code 76140, or in the case of a Medicare patient, use the code for the radiological exam with a -26 modifier attached. In either case, the presumption is that the X-ray consult is done independently of any E/M service provided to the patient by the radiologist.

 

[mitchellde]

If the radiologist that originally read the film and billed the interpretation request your advice and reading then you would bill the 76140. If a physician has performed the service in their office and provides a wet read but sends it to you for interpretation then you bill the same radiology code they used with the 26 modifier, they must bill using the TC, a wet read is part of their E&M. There can be only one official interpretation of the film unless the radiologist requesst a consult for an additional reading. When billing the 76140 you must have in your note the request from the radiologist for the consult and the reason for this. Most films do not need a second interpretation and you must have good documentation as to why this is being done.

 

[sbetts]

according to Clinical Examples in Radiology, Spring 2009, in a situation in which a referring physician requests a formal second opinion of a previously reported CT exam, upon exam of the CT, the consulting physician provides his or her opinion to the referring physician in a written report, the specific procedure code with mod -26 should be reported.

Shena Betts, CPC, RCC

 

[mitchellde]

I do not think that will pass the edits, that is why the 76140 code was created.

 

[jbaird]

I would bill this with the body area CPT code and the 26 modifier. However, if the physician that performed the x-ray bills globally (without modifier TC) and your radiologist bills with a 26 modifier you will receive a denial. It really just depends on which charge the insurance company receives first. One of you will receive a denial. If this is an office your radiologists will be reading for often enough, you can discuss whether the office will use a TC modifier. If they do not want to bill with a TC, you can discuss an "outside read" contract and have them pay you directly for the services. Then you would not bill the patient's insurance at all. You would send a bill to the physician's office based on the fee's discussed in your contract with them.