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Age old question...

  1. #1
    Default Age old question...
    Medical Coding Books
    Ok Please do not say NO just yet...
    I work for a Radiology practice that is subcontracted with a hospital and we do the readings for inpatient, outpatient and Emergency Room. (Modifier -26) To better understand exactly what I am asking I will give a scenario..
    Patient comes in the ER for pain in Right elbow after falling off a ladder. The ER physician orders a 3view x-ray of the right elbow and a 2view x-ray of the left elbow for comparison. (which we have a written order for) So the x-rays are taken and report is dictated. Question here is because WE the RADIOLOGISTS did NOT order the comparison and the ER physician DID can we bill out both x-rays as does the hospital?
    Any and all information would be appreciated especially any documented literature.

  2. #2
    Ah! I understand what you mean. I worked in a hospital as physician billing manager. The hospital had an agreement that all radiology billing was to come out of radiology. The E/D was not permitted to bill for any xray readings - the subcontracted radiology dept did the billing (using modifier -26) and the hospital itself billed for the technical component. We even had an out of state radiology group that would take on reading xrays from midnight to 8am, and the radiology docs would re-read the xrays in the morning, prepare the reports and do the billing.

    So, even though radiology did not order the xrays (the ED docs did), the subcontracted radiology group performed the xray, read the xray, generated a report, and filed the claim to the insurer.

    By the way, our E/D chief disliked the setup because the E/D had a tendency to run at a loss (much to the dismay of the hospital president!).

    Good luck,
    Last edited by xlbctso; 09-13-2007 at 07:13 PM. Reason: clarify "not"

  3. #3
    Thanks Louise
    But maybe to be more specific, the problem here is the you are not "supposed" to bill the comparison x-ray. But here is my logic behind it. As stated before since the ED's Dr ordered the testS I believe we should bill for both not just the elbow that was injured. It isn't as if the ED Dr only ordered the RT elbow and we (the radiologists) took separate films of the LT elbow to compare the two. If we did then I can see us not billing out the LT elbow even with a report because we are not the "ordering physician". So basically what I was asking is if anyone does this and if they do, where would I find literature on it so I can present it to my manager.
    I really appreciate the feedback guys!

  4. #4
    I think that if you bill both of them. It could come back to bite you. We do alot of retrospective reviews of providers on the payor side. To see where too much or too little is being paid. It could possibly come down to medical necessity of the non-problem elbow being read. That would be a fight you might not want to undertake. I would be really careful about billing that one and do ALOT more research on it before even suggesting that idea.

    Anthony Bush, CPC, CCP
    Medical Records Review Coordinator

  5. #5
    Louisville, KY
    Mr. Bush is on the right track here. There is no medical necessity for the comparison views.

    Anyone who would argue anything different should find the diagnosis code(s) in ICD for "comparison views." By my read, that would be "V72.5."

    Comparison views are not billable from the professional fee perspective. Logic: There is not medical necessity. Technically, the comparison views are ordered for an unaffected body part. They are a courtesy to the attending physician (ER, Surgeon, etc). Really, Radiology is only reading them because of hospital agreement/policy.

    I say play the prudent card here and just let those comparison views stay unbilled. Perhaps you can speak with your Radiologists in the future about changing the agreement they have with the hospital in that one respect.

    Coming from the very same background and having had the same question as you, I intimately know the sides of this issue.

    Good luck.

  6. #6
    Sorry - I should have read more closely. These were different which case, no medical necessity and therefore no billing.
    Last edited by xlbctso; 09-14-2007 at 10:17 AM. Reason: clarification

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