Carriers generally 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.
This is because 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, carriers must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. Payment for a second interpretation (which may be identified through the use of CPT modifier 77) may be made 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 only one claim for an interpretation is received, it must be presumed that the one service submitted was a service to the individual beneficiary rather than a quality control measure. The claim may be paid if it otherwise meets any applicable reasonable and necessary test.
When multiple claims for the same interpretation are received, payment for the first claim received is generally made. Payment for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient is generally made.
- Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed
- Consideration is not given to designation as the hospital's 'official interpretation' as a factor in determining which claim to pay
- Carriers pay for the interpretation submitted 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, carriers generally pay the claim because they would not know in advance that a second claim would be forthcoming. When carriers receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, they must determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, they pay that claim. In such cases, carriers must determine that the radiologist's claim was actually quality control and institute recovery action.
The two parties billing should reach an accommodation about who should submit the claim for these interpretations.
Claim Submission Instructions
For claims submitted electronically, the unusual circumstances must be submitted in the appropriate documentation record. Failure to use CPT modifier 77 and submit the necessary documentation will result in denial of the service. Limitations of liability and refund requirements apply.
Repeat Procedures by Same Physician
When the same physician interprets serial x-rays or EKGs performed on the same day, CPT modifier 76 must be submitted to indicate the service was repeated subsequent to the original procedure.
These guidelines are available on CMS' Web site at
www.cms.hhs.gov/Manuals/IOM/list.asp, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1.