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Radiology Coding Alert

Prevent 'Duplicate' Denials With Modifier 59 and 76 Know- How

Published on Sat May 09, 2009

Keep 71010 troubles at bay with this helpful time-stamp tip.

Reporting more than one chest x-ray for the same date can raise questions for payers. Are you accidentally reporting a single service more than once? If there was a second x-ray, was it medically necessary?

Answer your payer's questions up front by using modifiers and the narrative field, and help your physician's claims sail through the system.

Single View x 2? Think Mod 76

When radiologists interpret two x-rays on the same day that require the same code, coders need to investigate proper use of modifier 76 (Repeat procedure or service by same physician), says Sharon Wright, CPC, coding compliance auditor with Nemours health system in Jacksonville, Fla.

Scenario: A physician performs two chest x-rays (71010, Radiologic examination, chest; single view,frontal) on a patient with chest pain. The same radiologist interprets both films.

Solution: When repeating the x-ray is medically necessary, you should report the first service as usual and append modifier 76 to the second, says Sharon Cohen,RHIA, MSM, a Winthrop, Mass.-based consultant concentrating in diagnostic radiology.

Note that if you're reporting only the interpretation, you should append modifier 26 (Professional component),as well.

Example: You report:

• 71010-26

• 71010-26-76.

Consider Mod 59 for X-Ray No. 3

When the same radiologist interprets three x-rays on the same day that require the same code, coders must take a close look at which modifiers to use, such as modifier 59 (Distinct procedural service) in addition to modifier 76, saysWright.

Scenario: A physician performs three chest x-rays (71010) at different times on the same date. The same radiologist interprets all three films.

Solution: You will need to use modifier 76 again to show the second and third x-rays are not duplicate charges, Cohen says.

For this scenario, some payers may ask that you report two line items:

• line one: one unit 71010

• line two: two units of 71010 with modifier 76 appended.

Other payers may require you to report three lineitems, says Alice Wonderchek, CMBS, CPC, billing and coding specialist with Franklins and Seidelmann Subspecialty Radiology in Ohio.

Depending on the modifiers your payer prefers, your claim may look like this:

• line one: one unit of 71010

• line two: one unit of 71010 with modifier 76

• line three and subsequent lines: one unit of 71010 with modifier 76 and modifier 59.

And remember to append modifier 26 to each code if you're reporting only the professional service.

2-View Plus 1-View Needs Mod 59

For multiple x-rays on the same date that don't require the same code (such as one-view and two-view chest xrays),coders may face bundling issues and need to know when it's appropriate to use modifier 59 to override the edits, says Wright.

Scenario: A radiologist interprets a single view x-ray (71010) and a two-view x-ray (71020, Radiologic examination, chest, 2 views, frontal and lateral) taken for the same patient at different times on the same date.

For this scenario, assuming you have medical necessity for both exams, you'll have to override payeredits bundling one-view and two-view chest x-rays on the same date.

You should append modifier 59 to the lesser service to let the payer know that both exams were separate.

Example: On the claim, you would report:

• 71020

• 71010-59.

As in the other examples, you should append modifier 26 to each code if you're reporting the professional component only.

Resource: Modifier 59 misuse is a major target for auditors, so if you're feeling unsure about when it's appropriate, read "Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service" available on the Correct Coding Initiative overview page: www.cms.hhs.gov/NationalCorrectCodInitEd/.

Bonus Tip: Take Action With Time Stamps

To prevent denials, you should provide additional documentation in the narrative field, and include documentation of medical necessity for the repeat service(s) in the patient record.

Smart idea: One of the best things providers can do is to document the exam time in the radiology report -- for example, "portable chest 0320" on the first report and "portable chest 1345" on the second, advises Jackie Miller, RHIA, CCS-P, CPC, Coding Metrix Inc. vice president of product development in Powder Springs, Ga.

This time stamp isn't always technically possible, but when you can manage it, you may see billing and reimbursement accuracy improve, Miller says. Sometimes practices that code manually unintentionally submit two charges for the same exam because the coder receives two copies of the same report. But with the time stamp, you avoid this problem, she adds. Also, the time stamp helps prove to the payer that your radiologist really performed two separate studies and didn't just submit duplicate charges, explains Miller.

Different Interpreting MDs? Turn to Mod 77

Note that for physician claims, you should append modifier 77 (Repeat procedure by another physician) rather than modifier 76 if different physicians interpreted the exams.

Example: Suppose physician A performs and interprets the first x-ray, but physician B interprets the second x-ray. Instead of modifier 76, you'd attach modifier 77 to the second x-ray code to explain the second physician's involvement.

Modifier 77 tells an insurer that a claim from a separate physician is for repeating the same procedure performed earlier in the day by another doctor and is therefore valid and not duplicative.

Money matters: Modifier 77 is critical for correct reimbursement purposes. Medicare will reduce the fee on procedures appended with modifier 76. But carriers will not subject modifier 77 procedures to this reduction.

You're using the same CPT code, but the claim involves a different doctor represented by a different identification number.

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