Once you've met your carrier's guidelines for attaching modifier -26 (Professional component) to a radiological code (71010-71555), you're home free, right? Wrong. You now have to report the appropriate diagnosis code.
To ensure proper payment, your pulmonologist has to show medical necessity, and his diagnosis must justify the interpretive test, like an x-ray, says Tamra McLain, CPC, coding manager for HRA Medical Management Inc. in San Diego. For a list of Medicare's acceptable diagnosis codes, check with your local carrier or log on to
www.lmrp.net.
Here are some examples of diagnosis codes that support medical necessity at both Blue Cross Blue Shield of Tennessee and First Coast Service Options of Florida:
480.0-480.9 Viral pneumonia
481 Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia)
482.x Other bacterial pneumonia
483.0-483.8 Pneumonia due to other specified organism
484.1-484.8 in infectious diseases classified elsewhere
485 Bronchopneumonia, organism unspecified
487.0-487.1 Influenza, with pneumonia and with other respiratory manifestations
490 Bronchitis, not specified as acute or chronic
491.0-491.9 Chronic bronchitis.