Pulmonology Coding Alert

Learn when to report modifiers -26 and -77 with 71010

Even if your physician orders and interprets a chest x-ray or other diagnostic test, you shouldn't bill these diagnostic services separately from your E/M services. But you can consider the test a factor in the pulmonologist's medical decision-making when you choose the E/M level. Tip #1: Avoid Double-Billing Before billing for any diagnostic test interpretations that a technician at  another facility completed, be sure that another physician hasn't already laid claim to the service.

A possible scenario: The physician suspects that a patient has pneumonia, and he sends her to the hospital for a chest x-ray (71010, Radiologic examination, chest; single view, frontal).

Why you might not be able to bill the interpretation: In the hospital, a facility radiologist or other physician may interpret 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. 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. Tip #2: Disagreement May Warrant Rebill What if your physician disagrees and feels that he should bill for his interpretation? Many coders and physicians believe that if the ordering physician disagrees with the radiologist's interpretation, and if the ordering physician writes his own full report of the test, his interpretations counts as a correctly formatted report with a conflicting outcome.

Indeed, the Medicare Carriers Manual instructs that "practices deserve pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient." Bottom line: When you have the documentation to back it up, you should submit your claim with modifier -26 (Professional component) appended to the appropriate x-ray code.

Don't miss: If the technician who performs the diagnostic service also rereads the diagnostic test on the same date that the original physician performed his interpretation, you should also append modifier -77 (Repeat procedure by another physician) to the diagnostic service code.

But don't expect hassle-free payment from your insurer in this case. You should bill for your physician's reread only if his dictation supports it, coding experts say.

Example: If the original interpretation reveals the radiologist's opinion that the patient's chest x-ray is normal, but your physician sees a slight spot on the x-ray that may indicate pneumonia, you should send in copies of both interpretations and highlight the differences, along with your claim.

Remember: Your physician's documentation must demonstrate medical necessity of the service as well as professional interpretation. 

As Medicare explains, "a notation in the medical records saying 'fx-tibia' or 'EKG-normal' would not suffice [...]