Radiology Coding Alert

Check out these 3 common radiology coding queries, with expert responses directly from Medicare’s own policies.

Any seasoned coder will tell you that it can be challenging to locate firm answers to pressing radiology coding questions, because people tend to disagree on the answers and coding is not always an exact science. In those situations, it can be helpful to look directly to Medicare payers to iron out the coding rules. Once you know how Medicare wants you to report a service, you can work from there in determining how to best interpret your physician’s documentation.

Consider the following three questions, along with answers from either CMS or Medicare contractors on how to report these claims.

Question 1: PET Scan Modifiers

Question: We performed a PET scan and the payer rejected the claim due to the absence of modifiers PI or PS. Can you explain?

Answer: Ever since CMS debuted these modifiers in 2009, you must use them to describe the initial treatment strategy for biopsy-proven or strongly suspected tumors and for subsequent treatment strategy of cancerous tumors, CMS says in Chapter 13 of the Medicare Claims Processing Manual, which was updated on Nov. 10, 2016. The modifiers are as follows:

PI: Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.

PS: Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy.

Therefore, if a patient presents for a PET scan during the initial treatment strategy for tumors that the doctor has already diagnosed as being cancerous, you’ll append modifier PI to the appropriate PET code. If the patient instead presents after having dealt with a malignant tumor for a year but the physician is hoping to create a new treatment strategy to try and eliminate the cancer, you’d instead append modifier PS to the code.

Question 2: Some Codes Make You Mind the Calendar

Question: We billed an x-ray with code 71010 for a patient who had three back-to-back pneumonia cases. He was told to return after his course of treatment for another chest x-ray to confirm that his lungs were clear, but the claim was denied for lack of medical necessity. We’ve had these paid before, so we aren’t sure what the problem can be. Can you advise?

Answer: The answer may depend on how long the patient waited before returning to your office for the subsequent x-ray. In its policy for 71010 (Radiologic examination, chest; single view, frontal), Part B payer Noridian Healthcare Services says, “Routine, screening, pre-operative or periodic examinations in the absence of symptoms, signs or disease states as represented by covered ICD-10-CM codes will not be reimbursed. Following a stable chronic condition, generally one examination in a twelve-month period will be considered appropriate. In acute or subacute conditions or when new symptoms or findings are documented, more frequent examinations will be considered for reimbursement and are subject to medical necessity review.”

It’s unclear whether three bouts of pneumonia would qualify for Noridian’s “Stable, chronic condition” criteria, but if so, as long as you performed the healthy x-ray within 12 months after the patient’s last bout of pneumonia, you should be able to appeal the denial. If not, then chances are that you may not have the medical necessity to report the service.

Question 3: Two Interpretations Don’t Equal Two Payments

Question: We performed a clavicle x-ray and reported 73000 (Radiologic examination; clavicle, complete). The patient took the films and our interpretation to his orthopedic surgeon, who then billed for the professional component of 73000 by adding modifier 26 (Professional component) to the code, even though he knew that we had already written an interpretation (since the patient gave it to him). We therefore only got paid for the technical component, even though we performed the first interpretation. What can we do?

Answer: It’s likely that the orthopedic surgeon submitted his claim before you did, and therefore, Medicare paid him for the professional component and paid you for the technical component.

“Payment for a second interpretation of the same film is made only in unusual circumstances,” Palmetto GBA says in its coverage policy for x-rays. “Claims for the second interpretation of the same film must be submitted with CPT^® modifier 77 (Repeat procedure by another physician or other qualified health care professional) when performed by a different physician and must provide documentation as to why a second interpretation is medically reasonable and necessary. When an emergency room physician and a radiologist both perform interpretations of the same X-ray, both physicians should work together to determine who should submit the claim.”

It’s possible that the orthopedic surgeon saw something on the film that wasn’t in your interpretation, which could open the door to both of you collecting for the interpretation, if it meets the “reasonable and necessary” criteria that Medicare has, as stated in Palmetto’s policy above. You should contact the orthopedist’s office and determine why they performed the second interpretation, which may warrant you resubmitting the claim with a letter explaining the situation. It’s not a guarantee that you’ll collect, but it’s a start.