Wiki Second reading of an MRI

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To all who can answer this question:

Our ortho ordered an MRI... the interpretation & MRI films are received... the physician would like to append the -26 modifier to the MRI code for reading the MRI.. is this acceptable after we receieved the interpretation? I am confused because I am getting different answers from everyone, 2 of the 3 claims that were billed were paid (Medicare & NJBS). Any advice would be greatly appreciated.

Also, I just spoke with NJ Medicare & they informed me that a second reading is payable with the -26 modifier & a repeat modifier. I asked the question in every possible way, and they informed me that the payment was correct. Can anyone give me some feedback on this scenario.

Thank You
 
Just reading MRI?

If all the doctor is doing is reading the MRI, then that is part of his E/M service (worth 2 data points as part of MDM).

If he is truly re-interpreting the MRI - reviewing the films, and writing an interpretation report separate from his E/M documentation - then I believe that, yes, this can be coded with the -26 modifier.

When I was hurt in an auto accident and sent for MRI of the neck, the neurologist went over the films with me in her office ... but she never billed for a separate interpretation.

F Tessa Bartels, CPC, CEMC
 
Yes, he is re-interpreting & doing a seperate dictation. Per Medicare the payment was valid, I just needed to verify once more.

thank you!
 
I raised this question a few months ago...

https://www.aapc.com/memberarea/forums/showthread.php?t=8646

...and remain unclear on this whole situation. My Ortho docs re-read and interpret MRI's everyday, sometimes with different findings that that of the original interpretation. But, they insist that it would be "fraudulent" to re-bill for the professional component. I also, have received a lot of mixed information on this subject. Perhaps it deserves some trial and error?:confused:
 
I did further investigation with the AAOS & they informed me that it is billable since it's considered a "grey area"... Per the AAOS & Medicare, there isn't a policy on re-interpretation. Both Medicare & AAOS, advised that there must be sufficient documentation to support it. So far we have billed several & I have verified with Medicare if these payments were correct & they were valid. Per Medicare second readings are payable. Our MD had additional findings that weren't on the original interpretation. He didn't just read the MRI, he made a new interpretation. That's why we billed it. Since Medicare doesn't have a policy on this, they'll probably come up with one sooner than later. The -26 modifer was attached as well.
 
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Medicare does have a policy, but its stated in the context of an ER provider trying to bill an interp on top of a Radiologist. However, the same principles should apply to your situation.

Medicare Claims Processing Manual
Chapter 13
Section 100.1

Carriers generally distinguish between an “interpretation and report” of an x-ray or an EKG procedure and a “review” of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment. For example, a notation in the medical records saying “fx-tibia” or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An “interpretation and report” should address the findings, relevant clinical issues, and comparative data (when available).

Generally, carriers must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier “-77”) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.

Seth Canterbury, CPC, ACS-EM
 
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