Orthopedic Coding Alert

Reporting second reads should be the rare exception, not the rule

Just because your surgeon orders and interprets an x-ray, magnetic resonance imaging (MRI) or other diagnostic test doesn't mean you can bill separately for the service - but it does mean you can consider the test a factor in the surgeon's medical decision-making when choosing the E/M level.

Avoid Double-Billing

Before billing for any diagnostic test interpretations performed at other facilities, be sure that another physician hasn't already laid claim to the service.
 
A possible scenario: The orthopedist suspects that a patient tore her meniscus, and he sends her to the hospital for an MRI (73721-73723).
 
Why you might not be able to bill the interp: In the hospital, a facility radiologist or other physician may provide interpretations for all ordered tests as a matter of policy. 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, CHBME, president of Cash Flow Solutions Inc., in Brick, N.J., and a member of the AAPC National Advisory Board.

Disagreement May Warrant Rebill

What if your physician disagrees? Many coders and physicians feel that if the ordering physician disagrees with the radiologist's interpretation, and if the orthopedist writes his own full report of the test, his report counts as a correctly formatted radiological report with a conflicting outcome. 
 
In this scenario, you should submit your claim with modifier -26 (Professional component) appended to the appropriate MRI code. If the orthopedist performed his re-read on the same date that the original physician performed his interpretation, you should also append modifier -77 (Repeat procedure by another physician).
 
But don't expect hassle-free payment from your insurer in this scenario. You should bill for your physician's reread only if his dictation supports it, says Tracy E. Wheeler, CPC, coder at Albany Orthopedic Center in Albany, Ga. In addition, "the documentation would probably need to be sent in with the claim to improve the chance of reimbursement," she says.
 
Example: If the original interpretation reveals the radiologist's opinion that the patient's meniscus is normal, but your orthopedist sees a slight tear, you should send in copies of both interpretations and highlight the differences, along with your claim.

Consider Other Rereads Toward E/M Level
 
Although the surgeon may not be able to claim separate reimbursement for test interpretation if another physician has already provided a report, the orthopedist can consider his own reading of the test results as a component of medical decision-making, which may affect the level of any E/M service he provides, Cobuzzi says.
 
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 itself a key component of medical decision-making, according to CPT guidelines, and reading test results falls into this category.

Calculate E/M Points

If the physician documents that the actual image was reviewed, auditors can typically increase the "Amount and/or Complexity of Data Reviewed."
 
Example: In the emergency department, an emergency physician attends to a patient involved in a recent automobile accident. The patient complains of pain and tenderness in his ribs and chest. To check for rib fractures or other injuries, the physician orders an x-ray (for example, 71111, Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of four views).
 
The hospital radiologist provides the report, which then becomes part of the medical record that the surgeon must consider when making treatment decisions for the patient. The next day, the patient presents to the orthopedist's office and brings the films with her. The orthopedist reads the films and agrees with the hospital radiologist's interpretation.
 
Based on the key components of your physician's history, exam and medical decision-making (which includes consideration of the test results), the orthopedist documents a level-three office visit (99203 for new patients, 99213 for established patients).