If another physician has billed the professional component, you should not submit a charge
By Margaret M. Maley, RN, MS
Patients frequently bring X-rays from other doctors and facilities to an office visit with their orthopaedic surgeon. Can you bill for evaluating these films using modifier -26 to indicate professional component only? We often hear this question from orthopaedic surgeons and their staff in coding and reimbursement lectures. The simple answer is no. If another physician has billed the professional component, you should not submit a charge. Reading these X-rays is considered a part of medical decision-making and is a component of the E/M service. Let's look at some common examples.
Mr. Jordan comes to see Dr. Ortho with a fractured right radial shaft. Dr. Ortho orders an AP and lateral radiograph of the right forearm. This film is taken and evaluated by Dr. Ortho in his/her office. A "separate, distinctly identifiable" report is dictated (or written) and signed. NBA Insurance is billed using the codes for the initial office visit and 73090 (unmodified) for the X-ray. The unmodified 73090 indicates that Dr. Ortho is responsible for both the technical and professional component of the radiology exam.
When interpreting an X-ray, you must dictate/write a radiology report. In addition to your evaluation of the X-ray, the report should include patient identification, views that were ordered, body part being filmed and an indication of right and/or left limb. The physician's signature must be part of every report. CPT '99 (page 3) indicates that this report should be "separate." The definition of separate is a subject of much debate. Does this mean a completely separate sheet of paper or an X-ray report in the body of your office dictation with a separate heading? To avoid challenge from any carrier, the former would be your best bet.
However, the Health Care Financing Administration (HCFA) has given a verbal indication that a report in the body of the office note with a separate heading would be acceptable. In either instance, the report must be signed. If you are putting this report in your office dictation, signing the entire note should suffice. On a separate paper, a signature would be needed to make it valid and the report filed in the radiology section of the office record.
Mr. Jordan sees Dr. Ortho, who takes and interprets forearm X-rays. Seeking a second opinion on his own, Mr. Jordan sees Dr. Unbundler who reviews the films taken by Dr. Ortho. NBA Insurance is billed for an initial office visit or confirmatory consultation and 73090-26, indicating a separate charge for reading outside films from the office of Dr. Ortho. Wrong.
CPT '99 (page 7) describes the complexity of medical decision-making. It is stated that reviewing diagnostic tests, medical records and other information is defined as part of medical decision-making. In other words, it is part of the E/M service. This is expressly different than "performing and interpreting diagnostic tests ordered during a patient encounter" as Dr. Ortho did in scenario one. This is not included in the E/M service and may be billed separately with a "separate signed report" (CPT '99 page 3).
Mr. Jordan is rushed by adoring fans and falls off his pedestal. He suffers a concussion, a displaced right radius fracture and a buttock contusion. Dr. Ortho is called by the ER physician to consult on the fracture and buttock contusion. During his evaluation, Dr. Ortho orders AP and lateral X-rays of the right forearm and low back. Dr. Ortho can charge for reading these X-rays with the -26 modifier. He must put an "official" signed report on the chart. The HCFA stated that the interpretation that directly effects patient treatment should be billed.
In this scenario, Dr. Ortho is allowed to bill for his/her interpretation because no one else has charged for an evaluation. Carriers only want one bill so there must be an agreement between hospital radiology and the orthopaedic surgeon. No doubt you are thinking, "We always bill for reading outside X-rays and get paid." A word of coding caution: getting a claim rejected does not always mean you are billing incorrectly, just as getting paid is not always an indication that you are billing correctly.
Note: In the December 1998 Bulletin, Margaret Maley,
used the code 836.2 for the diagnosis for torn medial meniscus,
instead of 836.0. Maley says "if the tear is specified
as medial, .0 would be better than.2."
Margaret Maley, RN, MS, is a consultant with KarenZupko & Associates, a national management-consulting firm with expertise in orthopaedic coding, reimbursement and practice management.