Neurology & Pain Management Coding Alert

Here's when you can bill separately for duplex scan interps

Just because your neurologist orders and interprets a duplex scan for a stroke victim doesn't mean you can bill separately for the service. You can consider the test interpretation as a part of any E/M service the neurologists provides, however.

An Arkansas reader asks: "Why are we getting so many denials for 93880? Our physicians only read the results of the test, and therefore we attach modifier -26. In most cases, we use a diagnosis of 433.10."
 
According to our experts, the reader is doing at least two things correctly but may be overlooking a third problem: The neurologist may not be able to bill for the test interpretation at all. 

Begin With a Solid Diagnosis

If you're going to bill for duplex scan interpretation (or any diagnostic or therapeutic service), your claim must include a payer-approved diagnosis to show medical necessity.
 
Codes 93880 (Duplex scan of extracranial arteries; complete bilateral study) and 93882 (... unilateral or limited study) represent the current "gold standard" for diagnostic cerebrovascular ultrasound, which neurologist may use to examine the carotid arteries and verify a diagnosis of stroke.
 
Neurologists will order 93882 most frequently for a follow-up study rather than as an initial diagnostic test. Typically, an ordering physician will request a bilateral study (93880) for a full study of both carotid arteries. After locating and treating the suspected blockage, the physician may order a limited study for a specific site to determine the success of the treatment.
 
Rely on signs and symptoms: Because the neurologist generally will not have confirmed a stroke diagnosis (434.91, Cerebral artery occlusion, unspecified; with cerebral infarction) prior to testing, you must rely on signs and symptoms diagnoses to support medical necessity for diagnostic scans, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.
 
Typical signs and symptoms for stoke victims include cerebral atherosclerosis (437.0), paralysis (344.9), hemiplegia (342.91), loss of vision (369.9), occlusion of arteries (434.9x or 433.1x, as applicable), transient cerebral ischemia (435.9), aneurysms (442.9), stenosis (447.1), speech problems (784.5), and injury to blood vessels (904.9), among others.
 
What NOT to do: Never use a "rule-out" diagnosis of stroke to justify medical necessity for diagnostic testing, Hammer says. This labels the patient inappropriately as having a stroke when he may not have.
 
However, if testing confirms a stroke diagnosis, you may apply that diagnosis and use the signs and symptoms as secondary diagnoses.

Our Arkansas subscriber checks out here: She has chosen a diagnosis of 433.10 (Occlusion and stenosis of precerebral arteries; carotid artery; without mention of cerebral infarction), which most insurers, including most local Medicare payers, accept for 93880.

Append Modifier -26

If the patient undergoes a duplex scan using a facility's equipment, and the neurologist provides only the test interpretation, you must append modifier -26 (Professional component) to 93880/93882, as appropriate, Hammer says.

Appendix A ("Modifiers") of CPT explains that some procedures are a combination of a technical component and a physician (or professional) component.
 
If the physician provides both components of the service, she may report the appropriate CPT code with no modifiers. But, "When the physician component is reported separately," CPT specifies, "the service may be identified by adding modifier -26 to the usual procedure number."

In the latter case, the facility providing the equipment may claim the "technical component" of the service (the cost of equipment, supplies, technician salaries, etc.) by reporting the appropriate CPT code with modifier -TC (Technical component) appended.

Once again, our Arkansas subscriber checks out: She has attached modifier -26 to 93880 to show that the neurologist provided the test interpretation only.

Be Sure Another Physician Didn't Bill

If you're using an appropriate diagnosis and appending modifier -26 and still experiencing denials, you have to consider the possibility that the neurologist cannot bill for the test interpretation because another physician  has already claimed the service.
 
For instance, in the hospital setting, a facility radiologist or other physician may provide interpretations for all ordered tests as a matter of policy.
 
And if one physician interprets a test and provides a report outlining the result, no other physician can bill for the same service. The pay would consider this to be "double-billing," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc. in Brick, N.J.

Here's where our Arkansas subscriber may be running into trouble. If her neurologist orders the duplex scan in a facility setting, a radiologist may prepare an interpretation and report prior to releasing the test results to the neurologist.
 
Although the neurologist ordered the procedure, he cannot bill for the interpretation if another physician provides a report first.

Consider Test Results Toward E/M Level

Although the neurologist may not be able to claim separate reimbursement for test interpretation if another physician has already provided a report, the neurologist can consider her own reading of the test results as a component of medical decision-making. This, in turn, may affect the level of any E/M service she provides, Cobuzzi says.
 
This is because the amount and/or complexity of medical records, diagnostic tests and other information that the physician must consider when examining the patient is itself a key component of medical decision-making, according to CPT guidelines - and reading test results falls into this category.
 
Example: The neurologist examines a potential stroke victim in the hospital. He orders a duplex scan, for which the hospital radiologist prepares a report. The test results become part of the medical record that the neurologist must consider when diagnosing and treating the stroke victim.
 
Based on the key components of history, exam and medical decision-making (which includes consideration of the test results), the neurologist documents a level-three inpatient service (99223, Initial hospital care, per day, for the evaluation and management of a patient ...).
 
What if your physician disagrees with the radiologist's report? There are physicians and coders who feel that if the ordering physician disagrees with the radiologist's interpretation, and if the physician writes his  own full report of the test, the ordering physician's report counts as a correctly formatted radiological report with a conflicting outcome.
 
If this is the case, you may attempt to bill for the ordering physician's interpretation, Cobuzzi says. However, the payer will likely deny the charge, and you will be forced to appeal with the documentation.