Neurosurgery Coding Alert

Question: My surgeon and I have an ongoing debate about diagnostic testing, such as CT scans. He wants to bill for ordering and interpreting these tests, while I say that he cannot. Who's right?

New Jersey Subscriber

Answer: In the majority of cases, you are correct: The surgeon cannot report a separate code for ordering and interpreting diagnostic tests such as magnetic resonance imaging (MRI) or computed tomography (CT).

Example: A 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.

In an inpatient setting, a facility radiologist or other physician may provide interpretations for all tests as a matter of policy. And, if one physician interprets a test and provides a report of the result, no other physician can bill for the service: this would constitute "double billing."

You probably could not report the CT scan interpretation for the neurosurgeon in this case because, very likely, the hospital radiologist would prepare the initial CT scan report. 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. Moreover, the surgeon may not have credentials by the hospital to provide imaging supervision and interpretation.

What about differences of opinion? Some coders and physicians believe 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. In such a case, you may attempt to bill for the ordering physician's interpretation, but the payer will likely deny the charge.

Alternative: 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 (MDM), which may affect any E/M service level she provides. 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 a key component of MDM, according to CPT guidelines. If the physician documents that she reviewed the actual image, auditors can typically increase the "Amount and/or Complexity of Data" component 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 ...).

-- Technical and coding guidance for You Be the Coder and Reader Questions provided by Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.