February 13, 2017

Impact of Billing on Patient Care

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Whenever articles about coding appeals are written, they always seem to be about the facility or provider not getting paid – but have you ever wondered how it impacts a patient when the proper codes are not utilized?

Consider this example: a nursing school patient fell at school and initially went to a prestigious teaching facility for follow-up treatment. The initial diagnostic exams were taken from November into December 2014. The patient then was referred to yet another prestigious teaching facility and brought the original diagnostic exams, which had already been interpreted and billed by the first facility and were subsequently interpreted and billed in November 2015 by the second facility. She was seen by a neurologist at the second facility and underwent an evaluation and management, which included a physical exam, additional blood work and an EMG. The neurologist submitted the original diagnostic exams with the same codes as those used for the initial evaluation in 2014. The insurance carrier denied the second set of diagnostic billing as being out of network.

The patient kept appealing the case to the insurance carrier, citing the simple fact that new diagnostic radiologic studies were not performed, but rather it was a reading of the old films. These appeals went on until November 2016, when it finally reached a fourth level, during which the patient again stated that the diagnostic films billed in November 2015 were not new studies, but a rereading of films taken in November-December 2014.

The case was overturned in the favor of the patient, with a statement that the correct billing by the facility should have been 76140, "Consultation on x-ray exam made elsewhere, written report."

CPT® code 76140, “Consultation on X-ray examination made elsewhere, written report,” is intended to be used when, for example, Doctor "A" from Sunnydale Hospital sends a radiograph taken at Sunnydale to Doctor "B" at Goodhope Hospital. Doctor "A" asks Doctor "B" to offer his opinion on the radiograph. Doctor "B" writes a formal report on his interpretation of the radiograph and sends a copy of this report to Doctor "A."  

This code is not intended to be used by physicians within the same institution to reread radiographs taken at that institution. Levels of service (limited, intermediate, extended, comprehensive) include the "evaluation of appropriate diagnostic tests," which may necessitate that the attending physician personally review the radiographs taken on his patient. However, the physician cannot  use this code when the patient simply brings in the X-ray and the physician reviews/interprets the films. This service follows the same ideology as a consult service. Consult = 3 R's = request opinion, render opinion, report opinion.

However, when the patient brought her film studies to the neurologist for a second opinion, why were they submitted to the radiologist for a review? Could the neurologist asked for a second opinion not read the films as part of the consultation and therefore bill the appropriate E&M, which would encompass the patient bringing in the diagnostic studies? As per the above, the physician cannot use this code when the patient simply brings in the diagnostic films and the physician reviews/interprets the films.

CPT 76140 by definition is a service utilized by a radiologist or other consultant who reads an X-ray (or any diagnostic imaging study) but does not actually see the patient. This is not used when a patient brings the film for the provider to simply review as part of the patient’s past record.

Understanding this, one might presume that you should or could bill for X-rays brought into the physician’s office with the modifier -26 for professional component. That understanding is false. When a patient brings X-rays into a provider’s office, the films have already been read by the facility or provider that took them, and should have the report attached. Even if the report is not attached, a provider may not bill for reading films that have already been read. In certain circumstances in which the review of films takes more than 30 minutes, the proper code to bill would be 99358, the code for review of extensive records. However, this would almost never apply, as most doctors do not spend that amount of time reviewing films.

Therefore, the review of films, unless 30 minutes or more was spent on it, is neither separately coded nor reimbursed, but simply bundled into the exam and/or other services done the same day.
Denise M. Nash, MD, CCS, CIM

Denise M. Nash, MD, CCS, CIM, serves as vice president of compliance and education for MiraMed Global Services and as such she handles all Compliance and Education needs including migration to ICD-10. She has more than 20 years experience in the healthcare industry. Dr. Nash has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and value based purchasing (VPB) programs. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division.