Pulmonology Coding Alert

Question: In our pulmonary practice, patients often bring their x-rays and the written report from the radiologist who interpreted the test.When our pulmonologist reviews the films, is this considered an integral part of his or her visit or can we bill it as a second interpretation and report it with modifier -26 (Professional component)?

Virginia Subscriber

Answer: Reviewing the films and reports is an integral part of the physician service and cannot be billed as a second interpretation. The credit for this work is captured by the pulmonologist's E/M service documentation in the medical decision-making component. To receive credit for reviewing the radiology films and the radiologist's written interpretation of the films the billing provider must document this work in his or her progress notes, which contributes to the amount and complexity of the data reviewed.

The level of medical decision-making is based on the highest score in two of three categories:

1. number of diagnoses or treatment options
2. amount and/or complexity of data
3. risk of complication and morbidity or mortality to the patient.

The score for the categories is based on a point system or the risk to the patient.

In the subscriber's example, the pulmonologist's documentation of personal independent visualization of the image is worth two points and the review of the radiologist's report provides one point for a total of three points in the amount and/or complexity of data category. To further determine the level of decision-making, the clinical documentation must also include information related to the number of diagnoses or treatment options and/or the risk to the patient.