Wiki Modifier 26

[Jtk625]

I asked a mentor if a hand specialist sees a pt who brings films, can she charge for the professional component? I was told the ins co pays for the modifier once only and that would be from the radiologist. She decided to try to bill for the reading and she is getting paid from most insurances. Just want to make sure we are doing the correct billing.
Thanks for any input.

 

[mitchellde]

No you cannot use a 26 modifier for the overread. There should have been a professional interp when the radiology was performed. Your provider cannot bill for the interp just for reviewing the films brought in by the patient. On the other hand if no interp has ever been performed and your provider does perform an official interp with a separate report then you may bill with the 26 modifier.

 

[mderemer]

Normally if a non radiologist is reviewing an x-ray brought in by the patient, this viewing would be included in the provider's E/M level of service. I'm very surprised you are getting paid, and would be very careful going forward

 

[LLovett]

Of course you are getting paid, it has a completely different date of service from the first read so the insurance company has no idea that this is the same test they already paid for.

Getting paid is not the litmus test for correct coding and billing. The major question you need to be able to answer is, was the second reading medically necessary. If it was necessary, in cases where the first read missed something or was wrong, then it would be appropriate to bill for your providers read and bill, as long as they are creating a formal report. If it was not medically necessary then the provider should only count the 2 points in the MDM of their E/M assuming they document appropriately to support that.

Laura, CPC, CPMA, CPC-I, CANPC, CEMC