Wiki Xray denials from Medicare

[jeaner54175@yahoo.com]

We had two patients who were seen by our nurse practitioners and they each ordered xrays; we have a xray machine at the clinic with a technician but the xrays get sent out for a formal reading. Modifier TC was added to both claims but the claims came back with the denial provider not certified on DOS. The billing office called Medicare and we were told to also add modifier 26, so we did and they were denied again. The codes used were 74022 - TC with a dx of 564.00 and 71020 - TC with a dx of 959.19. Does anyone have any other suggestions?

Thank you,
Lisa Nieft/ CPC-A

 

[mitchellde]

first of all the dx codes are too non specific. Second you would not use the 26 modifier if your provider did not perform the official interpretation. It probably has to do with your nurse practitioner and her credentialing as far as xrays goes. I would check your credentialing with Medicare.
Also a Medicare rep is not allowed to tell you how to bill a claim as far as codes or modifiers. So just because one told you to use a 26 modifier does not mean they were correct.

 

[OCD_coder]

NEW information: non-physician practitioners cannot bill for the TC portion of radiology procedures. Retroactive 1/1/2013.
You were correct to bill with the TC modifier, but you can only bill under the supervising/Doc of the day-MD's NPI# as NP's cannot bill the technical component, it's not within their scope of practice.

PER CMS:
This is effective for those claims that are billed as non-incident to the physician's service. When the PA or NP is listed as the servicing or rendering provider, it has been determined that billing the technical component of an x-ray is not within the PA/NP scope of practice. If the PA/NP billing is submitted to Medicare as a non-incident to service, the PA/NP NPI can be reflected as the servicing or rendering provider for the professional component of the x-ray using the AMA-CPT code for the x-ray and Modifier 26. The technical (TC) component must be submitted showing the NPI of the supervising MD/DO on another line of the claim. For example:

CPT Code Servicing/Rendering Prov.

71010-26 PA/NP NPI #

71010-TC MD/DO NPI#

A claim submitted reporting an MD NPI for medically necessary x-rays will be covered. In addition, claims submitted whereby the PA/NP is providing care as “incident to” the MD/DO would not need multiple lines for the global reimbursement for an x-ray.

Additional guidance can be found in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-02, Medical Policy Benefit Manual, Chapter 15, Section 80.

 

[1073358]

NEW information: non-physician practitioners cannot bill for the TC portion of radiology procedures. Retroactive 1/1/2013.
You were correct to bill with the TC modifier, but you can only bill under the supervising/Doc of the day-MD's NPI# as NP's cannot bill the technical component, it's not within their scope of practice.

PER CMS:
This is effective for those claims that are billed as non-incident to the physician's service. When the PA or NP is listed as the servicing or rendering provider, it has been determined that billing the technical component of an x-ray is not within the PA/NP scope of practice. If the PA/NP billing is submitted to Medicare as a non-incident to service, the PA/NP NPI can be reflected as the servicing or rendering provider for the professional component of the x-ray using the AMA-CPT code for the x-ray and Modifier 26. The technical (TC) component must be submitted showing the NPI of the supervising MD/DO on another line of the claim. For example:

CPT Code Servicing/Rendering Prov.

71010-26 PA/NP NPI #

71010-TC MD/DO NPI#

A claim submitted reporting an MD NPI for medically necessary x-rays will be covered. In addition, claims submitted whereby the PA/NP is providing care as “incident to” the MD/DO would not need multiple lines for the global reimbursement for an x-ray.

Additional guidance can be found in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-02, Medical Policy Benefit Manual, Chapter 15, Section 80.

Can I please get the link to where this was quoted from?

 

[cgrimes161969]

Claim must be filed with Supervising MD. Also, CPT 74022 includes a CXR - 1 view (CPT 71010). Look at the number of views of the KUB and CXR to use the correct CPT.

 

[jennifersmith1]

I see this thread is from 2014 but is anyone still having denials with this? Medicare is paying them from what we are seeing. Does the technical component require a separate report or a supervising signature on the documentation with the NP? If it doesn’t require signature or separate report then how are you supposed to know to split bill?