Second Interpretation of X-rays and Electrocardiograms (EKGs)

Palmetto GBA will reimburse a second interpretation of the same EKG or X-ray only under unusual circumstances, 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. Absent these circumstances, Palmetto GBA may reimburse only the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient.

When Medicare Administrative Contractors (MACs) receive only one claim for an interpretation, they must 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 requirements.

When multiple claims are received for the same interpretation, MACs must generally pay for the first bill received. MACs generally pay this claim when all other Medicare billing and coverage requirements are met because they would not know in advance that a second claim would be forthcoming. MACs must pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient.

A provider may request a redetermination of a denied X-ray or EKG interpretation that they believe was not for quality control purposes and the interpretation contributed to the diagnosis and treatment of the patient. Documentation to support the medical necessity for the second interpretation must be included with the redetermination request. If it is determined that the first claim for an X-ray or EKG interpretation was paid in error, MACs will take recovery actions for the incorrectly paid service. The two parties involved can avoid this issue by reaching an accommodation about who should bill for these interpretations.

When a second interpretation meets the coverage criteria identified above, providers may append modifier 77 to the second interpretation when the service is initially billed to demonstrate  a repeat procedure by another physician. Providers should maintain documentation in the patient’s medical record to support the use of modifier 77.

References

• Medicare Claims Processing Manual, Chapter 13, Section 100.1 (PDF)
• CPT Modifier 77