Medi-Cal reimburses for only one interpretation of an individual X-ray procedure performed on a patient. Reimbursement is allowed for only one technical component (modifier TC) and only one professional component (modifier 26) for each individual X-ray when billed by any providers, for the same recipient and date of service. When multiple claims for the professional and/or technical component of an individual X-ray procedure are billed by different providers for the same recipient and date of service, only the first successfully adjudicated claim is reimbursed.
Two Interpretations
Two interpretations of the same X-ray are reimbursable only under unusual circumstances (for example, a second interpretation of a questionable finding by another physician). A second interpretation or “proof reading” by a second physician of an X-ray is considered a quality control activity and is not separately reimbursable.
Repeated X-Ray
If the same X-ray has been repeated by any provider for the same recipient and date of service, justification for the repeat X-ray must be included in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim, or on an attachment.
Modifier 26/ZS
The professional component (modifiers 26 and ZS) of radiology Procedure-4 codes 77261 – 79999 is not reimbursable when billed with an E&M procedure (other than 99211) when performed by the same provider, for the same recipient, on the same date of service.
