Radiology Coding Alert

Keep documentation and differentiate limited vs. complete assessments.

Radiological imaging may involve multiple components. You should know which components you can report and earn for. Also, you need to be sure which facility your physician used for the service and what was the extent of the radiological service.

Here are top three tips that can help you guard against losing your deserved payment.

1. Watch for Written Reports

When your physician performs a radiology procedure in the office or in a facility, such as the hospital, he should be paid for that work. Make sure the services of your physician meet the following criteria:

• Your physician should do the initial interpretation or reading of the film if you are billing for that work.

• Ensure that your physician provides a written report, which can be part of an operative note, of his interpretation. The report must be written, dictated, and signed by the interpreting physician, and it must be an integral part of a radiological service and interpretation. Keep this report in the chart, separate from office notes.

• The radiological reading should directly contribute to the diagnosis or treatment of the patient’s condition, and your physician should act or direct another specialist to act clinically based upon the reading of the image as noted in his report.

• Your physician must meet any accreditation requirements. Certain studies such as MRI, PET, and nuclear studies require accreditation before a urologist can perform the interpretation. Payers may also have their own accreditation requirements.

Additionally: Medicare requires an order in the medical records as well as a signature for all diagnostic tests ordered, so look for an order for each test and either a handwritten or electronic signature on orders for radiology studies. If you do not have physician signatures on the document for diagnostic tests ordered, medical records will need to show clear documentation of medical necessity for a test or have an attestation statement in the medical record.

2. Append the Right Modifier

There are three options for reporting and seeking payment for a radiological service:

• Technical component — This portion of the service’s payment covers the ownership of the equipment, payment for a technician, and payment for a contrast agent if administered. 

• Professional component — This portion of the service’s payment covers the work involved in reading and interpreting the study.

• Global — This portion of the service’s payment covers both the technical and the professional components.

When your physician performs the radiological study in the office, where the practice owns the equipment, report the procedure code as global with no modifiers.

Example: Your physician performs a retrograde pyelogram in the office. He owns the x-ray equipment. Report 74420 (Urography, retrograde, with or without KUB) without a modifier, since your physician owns the equipment and also interprets the study.

For radiology services your physician performs in an ambulatory surgical center (ASC) or in the hospital, where the facility owns the equipment, you’ll report the procedure code with modifier 26 attached for your physician’s work. The facility will report the same procedure code with modifier TC (Technical component).

Example: Using as example similar to the one above, your physician performs a retrograde pyelogram in an ASC. Report code 74420 (Urography, retrograde, with or without KUB). Append modifier 26 (Professional component) to the 74420, since your physician read and interpreted the x-ray, but the facility owns the equipment.

Remember: If your physician performs the radiological procedure in the office, you should not count the procedure as part of the E/M service. Instead, separately bill both an E/M service, if provided, and the radiology code. You will not need to append a modifier to the E/M code to seek separate payment. However, make sure that your physician documents a separate note for the radiological portion of the encounter on a separate page from the E/M note. Also, keep the images and x-rays in the patient’s medical records. 

3. Differentiate Limited and Complete

Your physician must perform and document a full evaluation of all anatomic regions (all organs) covered in the code you are billing. If an area or organ is described as “not seen,” the physician should explain the reason, such as overlying gas or overabundance of fatty tissue.

If your physician doesn’t document all of the required radiological elements in his report, you need to consider the procedure a limited study, rather than complete, and assign the appropriate limited code. Table 1 lists documentation requirements for complete and limited radiological assessments.

For example, if your physician performs a retroperitoneal ultrasound study but only visualizes the kidneys, you should report 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited) for a limited retroperitoneal ultrasound study rather than 76770 (... complete) for a complete study.