Neurosurgery Coding Alert

When your neurosurgeon does the interpretation for a magnetic resonance imaging (MRI), computed tomography (CT) scan, or other diagnostic test, you may run into hospital policy specifying only a facility radiologist can perform the interpretation.

But it's not all bad news. When the neurosurgeon 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.

Before billing for any diagnostic test interpretations in an inpatient setting, be sure that another physician hasn't already laid claim to the service, says Beth Thomsen,billing coordinator for the University of Toledo Physicians, LLC in Ohio.

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. Can you bill for the interpretation?

Solution: No. In a hospital or other inpatient setting, a facility radiologist or other physician may provide interpretations for all ordered tests as a matter of policy,Thomsen says. 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, CPC-P, CHCC, senior coder and auditor for The Coding Network, and president of CRN Healthcare Solutions in Tinton Falls, 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? Some coders and physicians 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.

Although the neurosurgeon may not be able to claim separate reimbursement for a 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.

In other words, -a radiologist can, in his/her interpretation,describe what the finding is, but it is the neurosurgeon who looks at the films to determine the course of treatment,- Thomsen says.

Reason: The amount and/or complexity of medical records, diagnostic tests, and other information that the physician must consider when examining the patient is a key component of medical decision making,according to CPT guidelines -- and reading test results falls into this category. For instance, if the physician documents that the actual image was reviewed, you 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 ...).

In cases in which 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,CCS-P, PCS, ACS-PM, CHCO, president of MJH Consulting in Denver.

CPT's Appendix A (Modifiers) notes that some procedures contain 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, Thomsen says.