Medicare Carriers Manual Part 3 - Claims Process Transmittal No. 1566

Section 15023. Interpretation of Diagnostic Tests, reflects the policy on interpretations of x-rays and EKGs adopted in the Federal Register of December 8, 1995.

    H.  Special Situations. --

           1.   Bone Mineral Density Studies (HCPCS Codes G0062 and G0063). -- Effective for services furnished on or after January 1, 1997, HCFA has established two new HCPCS codes that are to be used to describe nearly all bone densitometry studies. (See §50-44 of the Medicare Coverage Issues Manual for the coverage policy regarding these procedures.) HCPCS code G0052 is the appropriate code to use for peripheral skeletal studies, while HCPCS codes G0063 is used for central skeletal bone mineral density studies. Discontinue making payment under CPT codes 76070, 76075, and 78350 for bone density studies. The manner in which the codes apply to covered and non-covered services are as follows:

  • Single photon absorptiometry (CPT code 78350) on the peripheral skeleton is reported under HCPCS code G0062, and single photon absorptiometry on the central skeleton is reported under HCPCS code G0063.

  • Bone biopsy performed for the evaluation of bone would be unaffected by the change.

  • Photodensitometry (radiographic absorptiometry) is reported under HCPCS code G0062.

  • Dual photon absorptiometry (CPT code 78351) remains a noncovered service and may not be reported under HCPCS codes G0062 or G0063.

  • The coverage of computerized tomography bone mineral density studies and dual energy x-ray absorptiometry (DEXA) bone mineral density studies remains a matter of individual carrier discretion. If covered, HCPCS code G0062 is used to report a peripheral skeleton study by either method, and HCPCS code G0063 is used to report either procedure when performed on the central skeleton.

15023.     INTERPRETATION OF DIAGNOSTIC TESTS

    A.  X-rays and EKGs Furnished to Emergency Room Patients. -- Effective for services furnished beginning January 1, 1996, the policy on payments for the interpretation of an x-ray or an EKG furnished to a Medicare beneficiary in an emergency room by a hospital's radiologist or cardiologist, respectively, has been changed to permit payment for the interpretation to either the specialist or the treating physician. As a part of the revised policy, HCFA made a regulatory change specifying that the professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary's medical record maintained by the hospital. (See 42 CFR 415.120(a).)

HCFA minimizes your need to make decisions about which claim to pay when multiple claims for the interpretation and report of the same procedure are received by encouraging hospitals to work with their medical staffs to ensure that only one claim per interpretation is submitted. Take the following considerations into account in processing such claims.

Under the revised policy, distinguish between an "interpretation and report" of an x-ray or an EKG procedure and a "review" of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service since the review is already included in the emergency department evaluation and management (E/M) payment. For example, a notation in the medical records saying "fx-tibia" or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An "interpretation and report" should address the findings, relevant clinical issues, and comparative data (when available).

Generally, pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. Pay for a second interpretation (which may be identified through the use of modifier -77) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.

When you receive only one claim for an interpretation, presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.

When you receive multiple claims for the same interpretation, generally pay for the first bill received. Pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. Cease consideration of physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Do not consider designation as the hospital's "official interpretation" a factor in determining which claim to pay. Pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary. (This interpretation may be an oral report to the treating physician that will be written at a later time.)

If the first claim received is from a radiologist, pay the claim because you would not know in advance that a second claim would be forthcoming. When you receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, pay that claim. Determine that the radiologist's claim was actually quality control and institute recovery action. Encourage the two parties to reach an accommodation as to who should bill for these interpretations.

EXAMPLE A:     A physician sees a beneficiary in the ER on January 1 and orders a single view chest x-ray. The physician reviews the x-ray, treats, and discharges the beneficiary. You receive a claim from a radiologist for CPT code 71010-26 indicating an interpretation with written report with a date of service of January 3. Pay the radiologist's claim as the first bill. You do not have to develop the claim to determine whether the interpretaion was a quality control service.

EXAMPLE B:     Same circumstances as Example A, except that the physician who sees the beneficiary in the ER also bills for CPT code 71010-26 with a date of service of January 1. Pay for the first claim received. If the first claim is from the treating physician in the ER, and there is no indication the claim should not be paid, e.g., no reason to think that a complete, written interpretation has not been performed, payment of the claim is appropriate. Deny a claim subsequently received from a radiologist for the same interpretation as a quality control service to the hospital rather than a service to the individual beneficiary.

EXAMPLE C:     Same as Example B except that the claim from the radiologist uses modifier -77 and indicates that, while the ER physician's finding that the patient did not have pneumonia was correct, there was also a suspicious area of the lung suggesting a tumor that required further testing. In such situations, pay for both claims under the fee schedule.

EXAMPLE D:     You receive separate claims for CPT code 71010-26 from a radiologist and a physician who treated that patient in the ER, both with a date of service of January 1. Develop the claim to determine whether the findings of the radiologist's interpretation were conveyed to the treating physician (orally or in writing) in time to contribute to the diagnosis and treatment of the patient. If the radiologist's interpretation was furnished in time to serve this purpose, that claim should be paid, and the claim from the other physician should be denied as not reasonable and necessary.

 

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