Wiki Proper Use of Modifier 26

[Dnolan313]

Is it acceptable for a physician to bill an xray 73630-26 when he reads and interpretes findings to a patient. Considerations are :
1) Our Physician did not order the xrays
2) The physician who ordered the xrays left his practice and patient self referred to our clinic
3) We obtained xrays from the other medical clinic and patient states no one went over the findings with her previously.

 

[polycoder]

"he reads and interpretes findings to a patient" means face to face encounter? I would think it would be in the context of an E/M code. Reviewing test in the radiology section of CPT is worth one point for complexity.

 

[OCD_coder]

If the x-rays are performed at another facility and read by another provider, the carrier will only pay for one read.

If the provider orders the x-rays and they are performed either in their office or another site, but not formally read (very unusual situation) and the ordering provider/interpretation could be billed for the reading (modifier 26).

If the x-rays are performed on site and there is not a formal agreement for another radiologist to interpret the films, then the provider can bill for the full x-ray.

An interpretation must be documented for both in the patients record, with specificity of whom is interpreting.

In the context you have described, the x-rays were performed on another DOS, elsewhere, by another provider that has billed for the formal interpretation and your provider can only share the findings with the patient. The reading can only be scored in the MDM portion of the E&M service for your provider.

If the original reading is incorrect, your provider could bill for a new interpretation (I don't advise this as it has high policital connotations) and apply a modifier 26 and 77 and "maybe" recieve payment.

These are only a few scenarios - it is not a all encompassing list of possibilities.