Neurosurgery Coding Alert

Question: May I report 76140-26 to read x-rays that a patient brings with him or her to the office? I did not order the tests.

West Virginia Subscriber

Answer: No, you cannot bill separately for reading the test results, even if you append modifier -26 (Professional component). Because the radiologist or other physician reviewed the tests and dictated a report already (and presumably charged for these services), you would be double-billing if you report the services a second time. Rather, you should include reviewing laboratory and other diagnostic tests as part of any E/M service reported, which you may consider as a component of medical decision-making when assigning an E/M level.

According to CMS' Medical Decision-Making (MDM) audit grid, reviewing the radiologist's report reflects "minimal" amount or complexity of data, whereas reviewing the actual image is a "limited" amount or complexity of data. Reviewing both the report and image would qualify as a "moderate" amount or complexity of data. Your documentation should state, "Image reviewed." Remember that such a review constitutes only one of the two MDM components CPT requires.

You should report 76140 (Consultation on x-ray examination made elsewhere, written report) only if one physician specifically requests a second physician's opinion or advice regarding a specific film, and the interpreting physician (who usually does not meet the patient) must supply a written report to the requesting physician.