Pediatric Coding Alert

Sometimes a pediatrician, not a radiologist, interprets x-rays performed on a patient. To bill properly the interpretation for an x-ray performed by another physician, the pediatrician must use modifier -26 (professional component) correctly.
 
Radiology codes (70010-79999) consist of two components technical (modifier -TC) and professional (modifier -26). The party who owns the equipment bills for the technical component by appending modifier -TC to the radiology code, and the party who interprets the film bills for the professional component by appending modifier -26 to the same code. When the physician who owns the equipment also interprets the film a common situation in many pediatric primary care groups the physician bills the radiology code without modifier -TC or -26. The unmodified code includes both components.
 
A separate written report, clearly set apart from any notes about the encounter itself, is essential when billing for x-rays. Whether coding for both technical and professional components or with modifier -26, dictate a separate report for the interpretation, says Richard Haynes, MD, FAAP, a member of the American Academy of Pediatrics (AAP) coding and reimbursement committee and a pediatric orthopedist at Shriners Hospital for Children in Houston. "The x-ray report must be separate from the notes for the encounter," he stresses. You should use "I" language: For example, don't say, "The x-ray shows a fracture of the right ulna"; say, "I examined the x-ray, which shows a fracture of the right ulna." When written in this matter, your report will clearly show that you read the x-ray and are not simply repeating the radiologist's report.

If the scan is performed by a technician elsewhere and the pediatrician interprets it, the pediatrician should bill with the appropriate radiology code, with modifier -26 appended, says Diller Groff, MD, FAAP, chief of pediatric surgery at Kosair Children's Hospital in Louisville, Ky., and a member of the AMA CPT editorial panel.
 
If the pediatrician owns the x-ray equipment, takes the x-ray, and interprets it, he or she should bill the x-ray code with no modifier, Groff says.
 
X-ray taken elsewhere: For example, a child comes into your office with a fever, cough and respiratory distress on a Saturday morning. You send the child for a chest x-ray and ask the mother to bring the film back because you know the radiologist won't be in to interpret it. The technician performs the x-ray, and you interpret it as pneumonia. Bill 71020 (radiologic examination, chest, two views, frontal and lateral) with modifier -26 appended. You will also bill an E/M visit (99214-99215) for that day. Use diagnosis codes 480.x (viral pneumonia), 482.9 (other bacterial pneumonia; bacterial pneumonia unspecified) or 486 (pneumonia, organism unspecified). A separate radiology report is required.
 
X-ray taken in pediatrician's office: In another coding example of the same scenario, if you perform your own chest x-ray in the office, bill 71020 with no modifier. You will also bill the E/M for the office visit. Dictate a report that is separate from the encounter notes.
 
In another clinical example, a child has a wrist injury after falling from a swing, and the pediatrician wants an x-ray. He performs the x-ray in his office, interprets it and codes 73100 (radiologic examination, wrist; two views) with no modifier. Again, dictate a separate radiology report.

Sometimes, the radiologist interprets the x-ray, but the pediatrician wants to see it, too, most frequently to discuss it with the parents. Radiologists are usually "invisible," and parents need someone to explain the findings. In this case, don't bill with modifier -26, because the radiologist has already billed for the entire service professional and technical components. The payer will not cover both physicians' providing the same service.
 
For example, you send an infant for a skull x-ray to determine if there is any craniosynostosis. The radiologist reads the film and sends it back to you with the report. You don't get the report until the next day. Two days later, the parent and child come in to discuss the results with you. In the case of positive results, you explain that surgery will be necessary and answer any questions they have. You also show them the x-rays and explain the problem. You can bill an E/M for that visit and include discussing the x-rays as part of counseling. If counseling constitutes more than 50 percent of the visit time it probably will, because you have already conducted the initial examination of the child select a level based on time.
 
In another example, the pediatrician sends a febrile and coughing child for an x-ray and asks the mother to return with the film and the report. After going across the street to the hospital for the x-ray, the mother returns to your office later that day. When the mother returns, you see her and the child briefly, view the film and diagnose pneumonia.
 
In this common scenario, the pediatrician sees the child twice on the same day and interprets a chest x-ray, but can only bill one code for the two E/M services combined. Add up the work done for the first and second visits to arrive at a level, Groff says. The radiologist has already billed for reading the x-ray. It doesn't matter whether you interpret the x-ray a week later or the same day the x-ray was performed you cannot bill for the same service provided by the radiologist, Groff says; "You can only bill an E/M for seeing the patient." When a provider interprets an x-ray as part of an E/M service, an additional two points is assigned under the category of "amount and/or complexity of medical records, diagnostic tests and/or other information."
 
Only one person can bill for interpreting an x-ray. "If the radiologist bills for it, the pediatrician can't not with modifier -26, and not with an E/M," Haynes says. "If the pediatrician wants to interpret the x-ray performed by a radiologist, he needs to make an arrangement with the radiologist first."
 
Technically, both physicians can bill for interpretation, says Richard H. Tuck, MD, FAAP, founding chairman of the AAP coding and reimbursement committee and a pediatrician in Zanesville, Ohio. "But in reality, the insurance company will only pay for one," he says. "The one who gets his claim in first is the one who gets paid." To avoid ill will between physicians and to ensure that there will always be a radiologist to read your x-rays when you need one, you should not bill for interpreting x-rays when you also ask a radiologist to do such an interpretation, Tuck says

Under certain circumstances, the pediatrician who takes an x-ray would bill it with the technical component only and send it to a radiologist for further interpretation, Tuck explains. This would be more likely with neck, back or extremity x-rays; primary care pediatricians are more familiar with chest x-rays. In this case, append -TC (technical component) to the radiology code and allow the radiologist to bill for the interpretation appending modifier -26.