Neurosurgery Coding Alert

Question: A patient suffered a blow to the head and displayed symptoms of dizziness, sleepiness, slurred speech, and confusion. The attending physician ordered a CT scan (70460) to check for internal injuries and aneurysm. Our neurosurgeon admitted the patient for observation. Can we code the CT interpretation?

Louisiana Subscriber

Answer: Probably not. In a hospital or other inpatient setting, a facility radiologist often provides interpretations for all ordered tests as a matter of policy. Even if your physician provides the immediate interpretation used for treatment and the radiologist provides an "over-read" (secondary quality assurance review), hospital rules may give privileges (and therefore the fee) to the radiologist.

Remember: If one physician interprets a test and provides a report outlining the result, no other physician can bill for the same service. That would constitute double billing. Because you're coding for the admission as the admitting physician, you shouldn't report the interpretation for 70460 (Computed tomography, head or brain; with contrast material[s]).