ED Coding and Reimbursement Alert

Question: How should I report a scenario in which the physician did not take x-rays but interpreted them?

Missouri Subscriber

Answer: Report the same codes you would if the physician had taken the x-rays himself, but make sure you append modifier -26 (Professional component) to the code for the x-ray.

For example, if the emergency physician interprets two views of a patient's wrist, but someone else performed the x-ray, you should report code 73100 (Radiologic examination, wrist; two views) with modifier -26 attached. The modifier tells the payer that you are billing for the interpretation of the x-ray but not for taking the picture. (When you append modifier -26, the payer deducts the technical component from the payout on 73100.)

The hospital, on the other hand, would report 73100 with modifier -TC (Technical component) to show the payer that it is billing for taking the x-ray but not for the interpretation. (The professional component is deducted from the payout on 73100 with modifier -TC.)

For example, if a patient presented in the ED with a suspected broken arm, and your ED physician interpreted the x-rays, you would report 73090 (Radiologic examination; forearm, two views) with modifier -26.

The reimbursement race begins when the visit ends -- but not between the hospital and the ED physician. Because the hospital is billing for the facility component and the ED doctor for the professional services, payers won't have a problem reimbursing both sides. The trouble starts when, in many instances, two entities bill for professional services -- usually, the radiologist and the ED physician. Although CMS mandates only paying the physician providing the reading at the same time as the patient's care, many private insurance companies (incorrectly) only pay the first claim they receive.

Smart idea: Get those modifier -26 claims out the door as soon as possible to ensure maximum, ethical reimbursement.