Wiki How to Bill Multiple Imaging Codes on Same Day for Same Patient

[carlystur]

Hi, everyone.

I am seeing many cases where a patient comes in only for imaging, such as a Lumbar MRI and Lumbar 2 or 4-view X-rays, on the same day. I am now being told by our Medical Director that the MRI and X-ray should go on separate claims when I could have sworn I was told by our biller that they should go on the same claim around when I first started coding for this practice. Which is the right way to do this? Should they go on separate claims or the same claim?

 

[xXxPARAGONxXx]

Generally, for the musculoskeletal anatomy (e.g., the lumbar spine), X-rays, being the cheaper and more conservative imaging modality, should be ordered, performed, and interpreted before MRIs are even considered.

https://www.ortho.wustl.edu/content...y-Orthopedics/Standing-X-Ray-Versus-MRI-.aspx

The bottom line — over the course of the entire study, Adelani found that MRIs were not necessary in half of the patients. “A less costly X-ray would have provided enough clinical information.”

The only other thing I can think of is the Multiple Procedure Payment Reduction (MPPR) (which many private payers, too, follow) on diagnostic imaging, but I don’t know if that would even apply in this case since one imaging is MRI and the other is X-ray.

 

[carlystur]

Thank you for the information. Maybe they're denying the MRIs for medical necessity anyway so it may not matter. I don't know what's being denied and what isn't unless it's something specific that I missed in coding the claim. All I am being told to do is code all office visits and diagnostic imaging and if there's a documentation issue to let the provider know.

 

[TThivierge]

Carlystur
Check out the modifiers PI and PS which can be used for MRI as long as previous or initial dates in documentation from radiologist.
I hope helped you
Lady T

 

[csperoni]

Carlystur
Check out the modifiers PI and PS which can be used for MRI as long as previous or initial dates in documentation from radiologist.
I hope helped you
Lady T

I don't code radiology, but I'm pretty certain this is incorrect. My understanding is that PI and PS are specifically only used for PET scans when doing initial or subsequent imaging on cancer patients.
From my non-radiology experience, whether or not the procedures go on the same claim or different claims should not matter UNLESS your employer is specifically trying to thwart a bundling or second procedure reduction by putting on different claims.

 

[amyjph]

I think we would need more information and to actually see documentation and what happened to help you. There could be a lot more going on here or there may not be anything. In some cases, it matters if you "split bill" meaning bill separate pieces of the encounter split onto different claims. In other cases, it does not matter at all. There is no NCCI edit between 72148 (MRI spinal canal and contents lumbar w/o contrast) and 72110 (4 view spine XR lumbosacral) for example. So, splitting wouldn't matter when it comes to that. What could possibly matter is the MPPR (Multiple Procedure Payment Reduction) for Radiology. It's for the work involved with prep, draping, supplies, etc. done at the same session.

I would also ask why the MRI and X-Ray are being done on the same date, especially if this is an in-office orthopedic service, unless they find something concerning or urgent on XR and need the MRI stat. Or, have to take the patient to surgery urgently.

MRI normally require pre-auth (unless MCR or MCR Advantage), and as suggested above, the X-Rays would normally be done prior to that and not on the same day. It "could" happen but I would ask why.
Is this a non-op spine (physiatry) or spine surgeon office? Is the office billing for the global component, do they own the equipment, is the provider only billing the professional component? (TC/26 modifiers) Does the patient have multiple body areas requiring imaging and they did an XR on one anatomic area and MRI on a totally separate area?

There also could be reasons related to the accession number and the imaging system/EHR used when linking to the claim in the practice management system.
Did you ask the Medical Director, manager, or a supervisor the reason?

Now, if they are trying to get around a MPPR by doing this and the codes would have this policy applied, yet they are billing and being paid 100% for both where they should have gotten 50% for the lower RVU one, that's a problem. You would have to look up the codes, be billing the TC for both, and they would have to be codes that meet the rules for it.
MPPR Example from UHC: https://www.uhcprovider.com/content...ement/COMM-MPPR-Diagnostic-Imaging-Policy.pdf
"Under the CMS guidelines, when multiple diagnostic imaging procedures are performed in a single session, most of the clinical labor activities and most supplies, with the exception of film, are not performed or furnished twice. Therefore, CMS applies a reduction in reimbursement for secondary and subsequent procedures because payment at 100% for secondary and subsequent procedures would result in duplicative reimbursement for clinical labor activities only performed once. Examples of clinical labor activities, not furnished twice, include but are not limited to: Greeting the patient Positioning and escorting the patient Providing education and obtaining consent Retrieving prior exams Setting up the IV Preparing and cleaning the room"

p.s. - Do not reference PI or PS modifiers. This has nothing to do with your question.

 

[TThivierge]

Thank you for the information. Maybe they're denying the MRIs for medical necessity anyway so it may not matter. I don't know what's being denied and what isn't unless it's something specific that I missed in coding the claim. All I am being told to do is code all office visits and diagnostic imaging and if there's a documentation issue to let the provider know.

Hello
This is used at our facility if initial or repeat PET or MRI are done and noted in radiology report.This data is taken from my experience and 2 websites ofhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3162CP.pdf and https://www.medicalbillingcptmodifiers.com/2016/04/pi-and-ps-modifier-for-pet-scan.html.
For clarification purposes, as an example, each, different, cancer dx is allowed 1 initial treatment strategy (-PI modifier) FDG PET Scan and 3 subsequent treatment strategy (-PS modifier) . The 4th FDG PET Scan and beyond for subsequent treatment strategy for the same cancer dx . If a different cancer dx is reported, whether reported with a -PI modifier or a -PS modifier, that cancer dx will begin a new count for subsequent treatment strategy for that beneficiary. This data may depend on differ payers too
I hope this helps you
Lady T

 

[xXxPARAGONxXx]

Hello
This is used at our facility if initial or repeat PET or MRI are done and noted in radiology report.This data is taken from my experience and 2 websites of https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3162CP.pdf and https://www.medicalbillingcptmodifiers.com/2016/04/pi-and-ps-modifier-for-pet-scan.html.
For clarification purposes, as an example, each, different, cancer dx is allowed 1 initial treatment strategy (-PI modifier) FDG PET Scan and 3 subsequent treatment strategy (-PS modifier) . The 4th FDG PET Scan and beyond for subsequent treatment strategy for the same cancer dx . If a different cancer dx is reported, whether reported with a -PI modifier or a -PS modifier, that cancer dx will begin a new count for subsequent treatment strategy for that beneficiary. This data may depend on differ payers too
I hope this helps you
Lady T

Respectfully, neither of those links substantiate your assertion that “modifiers PI and PS...can be used for MRI as long as previous or initial dates in documentation from radiologist”.

Both of those links do reiterate what AAPC 2024 HCPCS Level II (pp. 561–562) states about the usage of modifiers PI and PS, which has nothing to do with MRI [by itself], but rather, PET and PET/CTs “to inform the initial treatment strategy [modifier PI] of biopsy-proven or strongly suspected tumors or subsequent treatment strategy [modifier PS] of cancerous tumors”.

Modifier		Definition
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	Append modifier PI to a code for positron emission tomography, PET or PET computed tomography, CT imaging studies that a provider performs to help plan the initial treatment strategy in patients with tumors, suspected to be cancerous by other diagnostic testing or proven to be cancerous through a biopsy. The provider uses the study to determine the location or extent of the tumor.
PS	Positron emission tomography (PET) or PET/computed tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy	A provider appends modifier PS to a positron emission tomography, or PET, or computed tomography, or CT scan to determine a subsequent treatment strategy of cancerous tumors when the provider determines he needs the PET study to determine a subsequent antitumor strategy for the patient.

What mention the CMS link does make of MRIs, it is for “...PET/MRI for...oncologic indications...”:

The CMS is revising Pub. 100-03, NCD Manual, section 220.6, to reflect that CMS has ended the coverage with evidence development (CED) requirement for 18 fluorodeoxyglucose positron emission tomography (FDG PET) and PET/CT and PET/MRI for all oncologic indications contained in Section 220.6.17 of the NCD Manual..

Despite being the coding novice that I may be, I don’t think modifiers can be used in a way that is not specified by the guidelines.

Although the OP’s original post was rather vague insofar as it did not discuss the medical necessity of the imaging studies, there is no mention of the imaging being for cancer. It was a lumbar MRI and a lumbar X-ray — no PET imaging. That precludes her from using those modifiers.

 

[carlystur]

I think we would need more information and to actually see documentation and what happened to help you. There could be a lot more going on here or there may not be anything. In some cases, it matters if you "split bill" meaning bill separate pieces of the encounter split onto different claims. In other cases, it does not matter at all. There is no NCCI edit between 72148 (MRI spinal canal and contents lumbar w/o contrast) and 72110 (4 view spine XR lumbosacral) for example. So, splitting wouldn't matter when it comes to that. What could possibly matter is the MPPR (Multiple Procedure Payment Reduction) for Radiology. It's for the work involved with prep, draping, supplies, etc. done at the same session.

I would also ask why the MRI and X-Ray are being done on the same date, especially if this is an in-office orthopedic service, unless they find something concerning or urgent on XR and need the MRI stat. Or, have to take the patient to surgery urgently.

MRI normally require pre-auth (unless MCR or MCR Advantage), and as suggested above, the X-Rays would normally be done prior to that and not on the same day. It "could" happen but I would ask why.
Is this a non-op spine (physiatry) or spine surgeon office? Is the office billing for the global component, do they own the equipment, is the provider only billing the professional component? (TC/26 modifiers) Does the patient have multiple body areas requiring imaging and they did an XR on one anatomic area and MRI on a totally separate area?

There also could be reasons related to the accession number and the imaging system/EHR used when linking to the claim in the practice management system.
Did you ask the Medical Director, manager, or a supervisor the reason?

Now, if they are trying to get around a MPPR by doing this and the codes would have this policy applied, yet they are billing and being paid 100% for both where they should have gotten 50% for the lower RVU one, that's a problem. You would have to look up the codes, be billing the TC for both, and they would have to be codes that meet the rules for it.
MPPR Example from UHC: https://www.uhcprovider.com/content...ement/COMM-MPPR-Diagnostic-Imaging-Policy.pdf
"Under the CMS guidelines, when multiple diagnostic imaging procedures are performed in a single session, most of the clinical labor activities and most supplies, with the exception of film, are not performed or furnished twice. Therefore, CMS applies a reduction in reimbursement for secondary and subsequent procedures because payment at 100% for secondary and subsequent procedures would result in duplicative reimbursement for clinical labor activities only performed once. Examples of clinical labor activities, not furnished twice, include but are not limited to: Greeting the patient Positioning and escorting the patient Providing education and obtaining consent Retrieving prior exams Setting up the IV Preparing and cleaning the room"

p.s. - Do not reference PI or PS modifiers. This has nothing to do with your question.

We are a neurosurgery/neurology practice and this does sometimes happen where the provider orders and performs an MRI and X-rays - usually of the cervical or lumbar spine area - on the same day. For the most part, they are for the same body part, for instance low back pain when ordering Lumbar imaging. We are performing and we own the equipment and we are billing for global, but we apparently have a deal where we send out the images to be interpreted by an outside company and we pay them separately.

I will see if I can ask about the reason to our office manager and/or our revenue cycle manager as it sometimes seems like our Medical Director does things the way he wants to do them regardless of whether or not it's the correct way to do them, such as using a locum tenens provider for way longer than allowed and not even using said provider properly (as in not following the guidelines for using a locum tenens provider).

I figured that the PI and PS modifiers were not correct as I did look them up on Google and saw they didn't seem to apply to my question.

EDIT: Moved a sentence to hopefully clarify what's happening more easily.

 

[taysin93]

MRI and X-ray should go on separate claims or not depending on the payers. First, I would agree to bill them on the same claim with modifier, it would save us some time instead of creating another claim. but a lot of time payer only pay 1 procedure in one area, the system is normally set up pay the lowest one. So, we either appeal every time this happens or to avoid it by billing separate claims.

 

[amyjph]

We are a neurosurgery/neurology practice and this does sometimes happen where the provider orders and performs an MRI and X-rays - usually of the cervical or lumbar spine area - on the same day. For the most part, they are for the same body part, for instance low back pain when ordering Lumbar imaging. We are performing and we own the equipment and we are billing for global, but we apparently have a deal where we send out the images to be interpreted by an outside company and we pay them separately.

I will see if I can ask about the reason to our office manager and/or our revenue cycle manager as it sometimes seems like our Medical Director does things the way he wants to do them regardless of whether or not it's the correct way to do them, such as using a locum tenens provider for way longer than allowed and not even using said provider properly (as in not following the guidelines for using a locum tenens provider).

I figured that the PI and PS modifiers were not correct as I did look them up on Google and saw they didn't seem to apply to my question.

EDIT: Moved a sentence to hopefully clarify what's happening more easily.

In that case it could be something to do with the external contract set up for the professional component situation or the payer being billed. It's all going to depend on who it is being billed to, internal practice setup and some other things. Not much is normally "all or nothing" or the exact same for every payer/practice.

You would have to check the payer policy for who is being billed. It's hard when you can't or don't see the result of the claim and the denial and rejection rates/scenarios. Again, in some cases it won't matter if it's a split claim or not.