Pulmonology Coding Alert

When billing for x-ray interpretations, some pulmonology coders follow the "first come, first served" philosophy for quick reimbursement they rush to submit claims first for x-ray interpretations to capture new revenue. But coding experts warn that you should avoid this practice like the plague.

Here's a familiar scenario: A primary-care provider (PCP) sends a patient complaining of fever and chest pain to a radiologist, who takes x-rays (71010, Radiologic examination, chest; single view, frontal) and diagnoses the ailment as acute bronchitis (466.x). The PCP then sends the patient to your pulmonologist. But the patient brought the x-ray film, not the radiologist's written report, which describes his or her diagnosis. So, without a report, can your pulmonologist now bill for his interpretation of the film?

No, says Felecia Bernstein, CPC, EMT, a coding and reimbursement specialist and president of the Monmouth Chapter of the American Academy of Professional Coders in Deal, N.J. The pulmonologist should not bill for an interpretation of the results if a patient's PCP sent him or her to a radiologist, who then made the diagnosis before sending the patient to the pulmonologist for treatment. The pulmonologist shouldn't bill for a reading, she says.

Indeed, CPT specifies that "The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M service." In other words, the radiologist performs and bills for an interpretation and then forwards the interpretative report to the PCP. Medicare and private carriers will pay only once for separately billed diagnostic services.

Report a Higher-Level E/M
Most radiologists write reports for every patient, coding experts say. When a patient presents to a pulmonologist with only the x-ray films in hand, the patient probably forgot to bring the report or the patient's PCP failed to forward the report to the pulmonologist.

If your pulmonologist wants compensation for attending to a patient who presents with films, he or she should document in the progress notes any extra work that could allow you to code for a higher E/M level, says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

For instance, a woman with a cough (786.2) and shortness of breath (786.05) presents to your pulmonologist, but she brings only the x-ray film not the radiologist's written report. The pulmonologist requests the patient's missing report, interprets the films as acute bronchitis (466.0), and develops a treatment plan. Because your physician ordered the records, he or she can receive credit for this in the "amount and/or complexity of data ordered/reviewed" category of medical decision-making. In this point system, the pulmonologist will receive one point for the decision to obtain records and two points for the independent visualization of [...]