Radiology Coding Alert

As with many advances in todays age of technology, the technological potential of teleradiology is outpacing the development of clear coding and adequate reimbursement policies.

The main challenge faced by professional coders is that there is no Teleradiology section in the CPT Codes . This is compounded by the fact that the technology is being used in a number of ways, each of which may pose unique reimbursement riddles:

In some instances, radiologists use teleradiology to provide consultative servicesand codes appropriate to those services may be assigned.

In other situations, the use of teleradiology may not be recognized at all and payment may be denied.
In still other cases, radiologists are using the technology to provide primary interpretations, and these situations are coded in the traditional manner (see box on page 22).

Determine Situations Where Teleradiology is Billable

Briefly, teleradiology is the process of digitizing an x-ray image and transmitting it via computer to a remote location where it can be viewed. Films are transferred quickly and easily, with great visual resolution, making it possible for physicians and radiologists to have convenient access to images.

The following scenarios illustrate cases where teleradiology is being usedand what coding alternatives
might be used to maximize reimbursement.

Scenario 1Reimbursement unlikely.: A radiologist in a large academic setting is interpreting films taken of a young woman patient with a suspicious uterine mass. She wants a colleagues input and transmits the images digitally to his office down the hall, asking her associate for his opinion.

In this, its simplest application, teleradiology most likely would not be reimbursed. This example is no different than a hallway conversation, where you grab a colleagues sleeve and ask his or her opinion, says Susan Callaway-Stradley, CPC, CCSP, an independent coding consultant in North Augusta, SC. The second radiologists reading isnt billable. In this instance, you must look at teleradiology merely as a convenience. Instead of having to pick up the films and carry them down the hall, the second radiologist can look at them on his computer.

The second radiologists involvement is not considered a consultation because it doesnt exhibit the three characteristics required for that category of service: 1) There must be a written request from the first radiologist for an opinion; 2) there must be a written response sent from the second radiologist to the first; and 3) the consultants opinion must be documented in the patients medical record and communicated to the requesting physician or other appropriate source.

Scenario 2: Billable as a consultation. A Radiology Practice in rural Oklahoma is viewing films of a patient with a rare gastrointestinal disorder. The group contacts another practice in Oklahoma City, knowing they have had greater experience with this condition, and transmits film for their review.

In this case, teleradiology is being used to conveniently bridge a geographic separation between a radiologist providing a primary interpretation of a film and a second radiologist supplying a legitimate consultation.
According to Callaway-Stradley, who was named Coder of the Year last year by the American Academy of Professional Coders, this scenario represents a situation where reimbursement is most likely. The second group received the requisite written request and responded with a written opinion. There clearly was a medical need, she says. The second group would code their charges in the written report as 76140 (consultation on x-ray examination made elsewhere, written report).

Scenario 3: Reimbursement unlikely. As in
Scenario 2, a group of radiologists seeks another opinion in a difficult case. However, this time they transmit their request and the patients x-rays out of state to specialists in New York.

This creates an entirely different set of problems, says Callaway-Stradley. But, she adds, the problems are independent of the coding challenges presented in scenarios 1 and 2. Chief among these problems is the licensing question. As the American College of Radiology has pointed out in recent months, radiologic studies performed in state A and interpreted by a radiologist in state B raise questions about the scope of, and conflicts among, state medical licensure requirements, regulations and laws.

Because of the complex and significant legal issues at stake, Callaway-Stradley predicts the states are going to have to determine appropriate regulations before Medicare and insurance carriers will even begin to consider payment issues. It is clearly an evolving issue and one we must watch closely.

As a result, there are no clear-cut coding guidelines for interstate teleradiology. Out-of-state radiologists
may attempt to assign code 76140 for a legitimate
consultationbut must also be prepared for denial, because of the unresolved licensing issues.

While the complex issues surrounding teleradiology are being examined, Callaway-Stradley encourages a cautious approach to coding. Because the necessary codes simply dont exist, reimbursement may be difficult. And I dont anticipate a change in this payment philosophy anytime soon. Telemedicine in general was in this position just a few years ago. Coding changes just dont keep up with technology. It was about six years after telemedicine was being widely used that national codes were developed.

How One Group is Making Teleradiology Work Craig Platenberg, MD, is a radiologist with MedTel, located just outside of Washington, DC. He admits that his group of teleradiologists may be described as pioneers in the field. We operate seven freestanding open MRIs in the United States and three in England, he says. What makes us different is that we read the images at a central location. Physicians send patients to one of the companys sites, where the images are taken and transmitted for him or one of his colleagues to interpret. We arent in the role of consultant, Platenberg points out. We provide primary diagnostic services. We just happen to operate from a remote site. After the scans are complete, patients leave the site with a copy of their films, and the requesting physician receives a complete report from the teleradiologist within 24 hours. Because MedTel radiologists are the primary interpreters of the images, Platenberg says they have had no denials based simply on the fact that they are operating as teleradiologists. They have sidestepped the licensing controversy by attacking it head-on: All MedTel radiologists have become licensed in all 14 states where MedTel conducts business. We understand the sensitivities to the licensing question, Platenberg says. So we addressed it directly.