X-rays and EKGs Furnished to Emergency Room Patients
The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary’s medical record maintained by the hospital. (See 42 CFR 415.120(a).)
A/B MACs (B) 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, A/B MACs (B) 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.
When A/B MACs (B) receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.
When A/B MACs (B) receive multiple claims for the same interpretation, they must generally pay for the first bill received. A/B MACs (B) must pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Consideration is not given to designation as the hospital’s “official interpretation” as a factor in determining which claim to pay. A/B MACs (B) pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary. (This interpretation may be an oral report to the treating physician that will be written at a later time.)
If the first claim received is from a radiologist, A/B MACs (B) generally pay the claim because they would not know in advance that a second claim would be forthcoming. When A/B MACs (B) receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, they must determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, they pay that claim. In such cases, A/B MACs (B) must determine that the radiologist’s claim was actually quality control and institute recovery action.
The two parties should reach an accommodation about who should bill for these interpretations. The following examples apply to A/B MACs (B):
A physician sees a beneficiary in the ER on January 1 and orders a single view chest x-ray. The physician reviews the x-ray, treats, and discharges the beneficiary. An A/B MAC (B) receives a claim from a radiologist for CPT code 71010-26 indicating an interpretation with written report with a date of service of January 3. The A/B MAC (B) will pay the radiologist’s claim as the first bill received. A/B MACs (B) do not have to develop the claim to determine whether the interpretation was a quality control service.
Same circumstances as Example A, except that the physician who sees the beneficiary in the ER also bills for CPT code 71010-26 with a date of service of January 1. The A/B MAC (B) will pay the first claim received. If the first claim is from the treating physician in the ER, and there is no indication the claim should not be paid, e.g., no reason to think that a complete, written interpretation has not been performed, payment of the claim is appropriate. The A/B MAC (B) will deny a claim subsequently received from a radiologist for the same interpretation as a quality control service to the hospital rather than a service to the individual beneficiary.
Same as Example B except that the claim from the radiologist uses modifier “-77” and indicates that, while the ER physician’s finding that the patient did not have pneumonia was correct, there was also a suspicious area of the lung suggesting a tumor that required further testing. In such situations, the A/B MAC (B) pays for both claims under the fee schedule.
The A/B MAC (B) receives separate claims for CPT code 71010-26 from a radiologist and a physician who treated that patient in the ER, both with a date of service of January 1. The first claim processed in the system is paid and the second claims will be identified and denied as a duplicate. If the denied “provider” is the radiologist and he raises an issue the A/B MAC (B) will develop the claim to determine whether the findings of the radiologist’s interpretation were conveyed to the treating physician (orally or in writing) in time to contribute to the diagnosis and treatment of the patient. If the radiologist’s interpretation was furnished in time to serve this purpose, that claim should be paid, and the claim from the other physician should be denied as not reasonable and necessary.
Helpful Hints for Billing
* Always use Modifiers. For example for the CPT-4 code (chest-x-ray) 71010 use either modifier -26 or –TC to denote either the professional code or technical code.
* Pharmacy Providers may use Point of Sale
* Use website to view status of bill or authorization for services rendered: http//:owcp.dol.acs-inc.com
* Outpatient Hospital services can be billed on the UB 92 form with appropriate Revenue Center Codes requiring CPT/HCPCS codes.
* All bills must contain the DEEOIC’s 9-digit case number of your patient or client and your 9-digit provider number.
* Laboratory, x-ray, physical therapy, and clinical tests such as EKGs, etc. must be identified with the correct CPT code.
* Facility charges for ambulatory surgical center/outpatient surgery billing must be billed using the surgical CPT code. Modifier SG should be used.
* When billing for inpatient services, your Medicare number must be included.
Reporting example: For a single frontal chest x-ray, the claim for CPT code 71010 (Radiologic examination, chest; single view, frontal) would be submitted in one of the following two ways:
1. either as a global service, if the professional and technical components are submitted together:
* Global – 71010
2. or as individual claims for the professional and technical components, when submitted separately:
* Professional only – 71010-26 and
* Technical only – 71010-TC
Professional bilateral radiology services are reported as two lines with LT and RT modifiers
Reporting and Documentation Rules and Criteria for Modifier 59:
The reporting of modifier 59 by a provider must follow the Health Plan’s requirements for correct coding.
• The Health Plan requires that modifier 59 must be appended to the denied code as described in the National Correct Coding Initiative (NCCI) Column 1/Column 2 edits
• We follow CPT’ coding guidelines requiring that modifier 59 only be used when there is no other appropriate established modifier, and “only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.2 ” Documentation is not required for a claim to be processed when modifier 59 is appended to a CPT/HCPCS code. However, if requested, the patient’s medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. The Health Plan follows CPT in requiring that documentation must support:
• a different session or patient encounter
• a different procedure or surgery
• a different anatomical site or organ system
• a separate incision/excision
• a separate lesion
• a separate injury
The following example indicates the appropriate use of modifier 59 when two procedures codes that are not ordinarily performed together on the same day by the same provider, are reported.
• A single view chest x-ray (71010) is part of the more comprehensive radiologic exam described by 74022 (radiologic examination abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest). If these two procedures are reported together, 71010 will be denied separate reimbursement.
• When a single view chest x-ray is performed on the same day but at a different time and patient encounter, appending modifier 59 to CPT 71010 is warranted to signify that a separate and distinct service was performed. (Modifier 59 should follow modifier 26, if services are done in a facility setting.) Modifier 59 will override the procedure unbundling edit and 71010 will be eligible for separate reimbursement.
What is changing?
When CPT code 71010 and CPT code 71100 are billed for the same day, the codes will be recoded to the comprehensive CPT code or CPT code 71101.
* CPT code 71010 is defined as “radiologic examination, chest; single view, frontal.”
* CPT code 71100 is defined as ”radiologic examination, ribs, unilateral; two views.”
* CPT code 71101 is defined as “radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views.”
Why is Humana implementing this change?
CPT code 71010 is for a chest X-ray, and code 71100 is for rib views. If both views are being performed, the appropriate code to bill is code 71101, which is for the rib and chest views, per AMA’s CPT description.