Neurosurgery Coding Alert

Question: Our surgeon makes an interpretation for the diagnostic studies for a patient who presents with head trauma. The documentation has the impressions of the procedures provided by the radiologist who performed the procedures. Can we bill for the surgeon's interpretation? Is this interpretation inclusive in E/M services? Can we append modifier 26 in this case?

New York Subscriber

Answer: Your neurosurgeon may interpret the reports of diagnostic investigations like the magnetic resonance imaging (MRI), computed tomography (CT) scan, or another diagnostic test. In this case, you may be in conflict with the hospital policy specifying only a facility radiologist can perform the interpretation. Any coding for the neurosurgeon's interpretation in this case implies double-billing.

Hospital policies call for radiologists' interpretation: 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. You cannot bill for the interpretation services of your neurosurgeon.

Only one physician can bill for interpretation: Only one physician can bill for the interpretation of the diagnostic test(s). The physician who bills needs to have a complete report and should have signed the report.

Conflict in interpretation can call for an appeal: Your surgeon may differ in the interpretation of the diagnostic test. In this case, your physician can document a formatted report. You may attempt billing for this service but most payers will deny the charge.

Interpretation may be inclusive in MDM and E/M services: Although your neurosurgeon may not be able to claim separate reimbursement for a test interpretation if another physician has already provided or will provide a report, the physician's interpretation of the test results may be considered as a component of medical decision-making, which may affect the level of any E/M service that the physician provides. In this case, the test results become part of the medical record that the surgeon must consider when diagnosing and treating the physician. Based on the key components of history, exam, and medical decision making (which includes consideration of the test results), the surgeon can document a level-three observation admission (99220, Initial observation care, per day, for the evaluation and management of a patient ...).

Append modifier 26 to cases that qualify: In cases in which your surgeon 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 service.