Orthopedic Coding Alert

Question: We send our patients to an outside lab for x-rays, but we interpret the films in our office. Most of our claims for reading the x-rays have been denied, and we discovered that this is because the radiology lab bills for both the professional and technical components of the x-ray codes, so the insurer denies our claim for the professional component. How do we justify billing modifier -26 (Professional component)?

Pennsylvania Subscriber

Answer: It sounds as though the lab is at fault and should have been billing only the technical component of the x-rays with modifier -TC. First talk to the x-ray lab director to discuss any misunderstanding in your orders. The lab may be operating under the misconception that you require a full-service x-ray report, and therefore it is billing for both components of the code.

Assuming that billers at the lab are erroneously billing the full fee rather than just the -TC modifier, once you make them aware of the problem they should support your appeals to the insurer by taking responsibility. Write to the carrier and offer to send them documentation to back up your claims for interpreting the x-rays. The notes should always include a separate written report about the findings from reading the x-rays. This information should not be included in the physician's notes from the evaluation itself, but should be elsewhere in the patient's chart.

In addition, the physician should always refer to herself in the first person in her notes. For instance, instead of saying, "The x-ray shows a fracture ...," the notes should say, "I examined the x-ray and found a fracture ..." This will show that the orthopedist read the x-ray and is not simply repeating a radiologist's report.