Neurosurgery Coding Alert

Don't bill for diagnostic test analysis if another physician already has

Just because your neurosurgeon orders and interprets magnetic resonance imaging (MRI), a computed tomography (CT) scan or other diagnostic test doesn't mean you can bill separately for the service.

But even when the surgeon cannot bill separately for the interpretation, you can still consider the test as a factor in medical decision-making when assigning an E/M level.

Avoid Double-Billing

Before billing for any diagnostic test interpretations in an inpatient setting, be sure that another physician hasn't already laid claim to the service.

A common scenario: The patient has suffered a blow to the head and displays symptoms of dizziness, sleepiness, slurred speech and confusion. To check for internal injuries and aneurysm, the attending neurosurgeon orders a CT scan (70460, Computed tomography, head or brain; with contrast material[s]). The test reveals no evidence of serious injury, and the surgeon admits the patient for observation.

Why you can't bill the interp: In the hospital or other inpatient 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 because this would constitute "double-billing," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc. in Brick, N.J.

You probably could not report the CT scan interpretation for the neurosurgeon in the above scenario because, very likely, the hospital radiologist would prepare the initial report for the CT scan. Even when the neurosurgeon provides the immediate interpretation used for treatment and the radiologist provides an "over-read" (secondary quality assurance review), hospital rules may give the charge to the radiologist.

What if your physician disagrees? There are those coders and physicians who think 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. But the payer will likely deny the charge, and you will be forced to appeal with the documentation.

Consider Test Results Toward E/M Level

Although the neurosurgeon may not be able to claim separate reimbursement for test interpretation if another physician has already provided a report, the neurosurgeon can consider her own reading of the test results as a component of medical decision-making, which 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.

If the physician documents that the actual image was reviewed, auditors can typically increase the "Amount and/or Complexity of Data" from "minimal" to "moderate."

Example: In the common scenario described above, the test results become part of the medical record that the neurosurgeon must consider when diagnosing and treating the accident victim.

Based on the key components of history, exam and MDM (which includes consideration of the test results), the neurosurgeon documents a level-three observation admission (99220, Initial observation care, per day, for the evaluation and management of a patient ...).

When You CAN Bill, Append -26

In those cases when the neurosurgeon legitimately provides the only interpretation and report for a diagnostic study, you must still remember to append modifier -26 (Professional component) to the appropriate CPT code to describe the test, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

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, he 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.

Therefore, if the neurosurgeon in our common scenario provides the initial interpretation and report for the CT scan on the head-injury patient, you are justified in reporting 70460 in addition to any E/M services the surgeon provides.

You should append modifier -26 to 70460, nevertheless, to show that the surgeon did not provide the equipment on which the test was conducted.