Orthopedic Coding Alert

Question: Our local community hospital has an
x-ray facility located in our office and provides the x-ray technician. They bill for the technical component. Our physician, an orthopedic surgeon in solo practice, interprets the x-rays and we bill for his interpretation using the -26 modifier (professional component). However, Medicaid is denying our x-ray interpretation, stating that radiology interpretations are considered part of the professional care of the patient. According to the Texas Medicare Carriers Manual (MCM), we should be paid. I have verified that I am submitting claims correctly. The payer said that the reason our claims were being denied was that the hospital was billing for these interpretations as well. I contacted them and they said they were billing for the technical component only. When I told that to the payer she said another reason we were being denied was that we do not own the x-ray equipment or the building. We have not been paid for x-ray interpretations since June 1998. Any suggestions?

Ronald W. Conner, MD
Pleasanton, TX

Answer: Coding and reimbursement specialists pointed out several areas to investigate before launching an appeal.

1. Is the x-ray part of a larger service rendered to the patient? Or is the work done as part of a quality assurance initiative for the hospital?

If the orthopedist is actually seeing and treating the patient based on that x-ray, then the x-ray is considered part of the medical decision-making component of the Evaluation and Management (E/M) service and therefore should not be billed separately. But if the orthopedist is performing interpretations as a complete and distant service for the hospital, he or she should be paid by using modifier -26.

Note: A separate, signed written report should be included in the patients chart. A one-line statement saying knee x-ray normal in the notes does not qualify as an interpretation. The orthopedist must report just as a radiologist would. For example, our views of X bone were obtained. No fractures, etc.

2. Does your payer recognize modifiers? Some dont, reminds Camille H. Norris, CPC, coder for Pamilco Orthopedics, in Washington, NC. Previously, Norris had a similar problem with that states Medicaid. If a payer does not recognize modifiers, then the hospital may be receiving full reimbursementno matter if the hospital is billing correctly with a technical component, she points out.

3. Does the hospital have a radiology agreement with an outside radiologist? If so, could that entity be billing for the interpretations as well? In that case, youll need to work with the hospital and the radiologist to set up a payment policy. The Heath Care Financing Administration (HCFA) says they leave it up to the facility to determine which physician should bill for interpretations. However, they prefer to see the claim submitted by the physician who used the information for direct treatment of the patient. Their bottom line is that they dont want to see duplicate claims and wont pay for more than one interpretation. For example, HCFA wont pay for the second reading done for quality assurance purposes, even though that action is a vital hospital protocol. Clarify your hospitals billing arrangement.

4. Are you completing the form correctly? Check the payers claim requirements for leased services to make sure the link to biller of the technical component is clear.