Pulmonology Coding Alert

Question: We performed a chest x-ray and then had to repeat it later in the day when the patient returned to the office. We have done this before with no issues, but this time the claim for the second service was denied. Can you advise?

Codify Subscriber

Answer: It's likely that you either forgot to add a modifier, or your diagnosis code did not support medical necessity for the second test. Although many such claims used to pass through on the first try, many insurers are now scrutinizing repeat chest x-ray claims.

Background: Duplicate denials for chest x-rays or EKGs have been identified as a common error by several Medicare Administrative Contractors (MACs). For example, according to Palmetto GBA's recent posting on the issue, denials for these services are climbing rapidly because providers don't appropriately bill the repeat services. The instructions for reporting legitimate duplicate claims are as follows, the MAC says on its website:

• Submit multiple 'identical' services on the same claim. Use the quantity field to reflect the number of services. If the services cannot be submitted on a single claim, use CPT^® modifier 76 and specify the exact times of each service.
• On electronic claims, use the documentation record to specify the exact times that each diagnostic » » service (e.g., chest x-ray, EKG, etc.) was done.
• On electronic claims, use the documentation record to explain why more than one diagnostic service was done on the same date by the same provider.
• Attachments (e.g., signed radiology reports, signed EKG reports, etc.) for paper claims must identify the patient's name, Medicare number, date of service and other pertinent information (e.g., times):
• On appeal, signed medical records (e.g., radiology reports, EKG reports, etc.) may be sent as evidence to show why more than one diagnostic service was billed on the same date by same or similar providers from the same group.

Noridian Healthcare Solutions, another Part B provider, offers the following example: "Provider performed two chest x-rays on same day. Billed the chest x-ray code with date of service 10/12/16 twice (i.e., on two separate claims). One claim submitted on 10/20/16; another claim submitted on 10/21/16. Both claims denied as duplicate. Both claims billed for same patient, same provider, same date of service, same charge, same CPT^® code, and same units without modifier."

In reality, Noridian says, if both services were medically necessary and distinct, 71045 (Radiologic examination, chest; single view) should be billed on the same claim, the first line of service with no modifier, and the second line should list 71045-76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional).

Resource: To read Palmetto's report on repeat chest x-ray and EKG denials, visit https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM Part B~Browse by Topic~Denial Resolution~8EELKX8677?open.