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Printed Date: 9/22/2015
The Medicare Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 13, "Radiology Services and Other Diagnostic Procedures," Section 100.1 "X-rays and EKGs Furnished to Emergency Room Patients" requires that the Medicare Administrative Contractor normally pay for only one interpretation of an EKG or X-ray furnished to an emergency room patient.
In simple terms, the intent of this regulation is to pay the interpretation used to diagnose and treat the patient.
Medicare Administrative Contractors (MACs) generally distinguish between an "interpretation and report" of an X-ray or an EKG procedure and a "review" of the procedure. 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.
We arrive at this determination 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, MACs 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. Absent these circumstances, reimbursement can only be made for the interpretation and report that directly contributed to the diagnosis and treatment of the patient. CPT modifier 77 should not be used solely because two interpretations were performed.
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 is generally made for the first claim received by the MAC. Payment must be made for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. As a rule:
If the first claim received is from a radiologist, MACs generally pay the claim because they would not know in advance that a second claim would be forthcoming. When MACs 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, pay that claim. In such cases, MACs must determine that the radiologist's claim was actually quality control and institute payment recovery action. Documentation may be submitted with the initial claim, or if a denial is received, the documentation should be submitted with the request for redetermination.
The documentation submitted must support that the interpretation results were provided in time to contribute to the diagnosis and treatment of the patient. This documentation may be submitted with the initial claim or if requesting an appeal, must be submitted with the appeal request. Including the time of the report submission to the treating physician might be one method to demonstrate that the report was sufficiently timely to be used in diagnosis or treatment. Interpretations provided days or hours after the care of the patient, would not meet policy requirements.
The Medicare IOM, in the same reference as noted above, indicates that the two parties should reach an accommodation about who should bill for these interpretations. Doing so can reduce or eliminate the need to submit additional documentation and reduce or eliminate the need to submit appeals.
A Few Examples
Palmetto GBA receives 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. The first claim processed in the system is paid and the second claim will be identified as a possible duplicate. If documentation was submitted with either the first or second claim, it will be reviewed for payment determination. If the documentation supports that the radiologist’s interpretation was provided in time to contribute to the diagnosis and treatment of the patient, that claim is paid, and the claim from the other physician would be denied as not reasonable and necessary, or if previously paid, overpayment collection action would be initiated. If the documentation submitted does not show that the interpretation was provided in time to contribute to the diagnosis and treatment of the patient, or if no documentation was submitted the claim will be denied as a duplicate.
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. Palmetto GBA receives a claim from a radiologist for CPT code 71010–26 indicating an interpretation with written report with a date of service of January 3. Palmetto GBA will pay the radiologist’s claim as the first bill received.
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. Palmetto GBA receives a claim from a radiologist for CPT code 71010–26 indicating an interpretation with written report with a date of service of January 3 and a claim from the physician who saw the beneficiary in the ER billing for CPT code 71010–26 with a date of service of January 1. The first claim received by Palmetto GBA will be paid, unless documentation is submitted with the claim to the contrary. 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. Palmetto GBA will 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.
Same as Example 3 except that the claim from the radiologist uses CPT 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 situations such as this, both claims can be paid.
Claim Submission Instructions
For claims submitted electronically, the unusual circumstances must be submitted in the appropriate documentation record or may be submitted via fax. 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.
If CPT modifier 77 is not appropriate, both the physician treating the patient in the emergency room and the radiologist may still submit documentation with the initial claim to support that the interpretation results were provided in time and/or used in the diagnosis and treatment of the patient.
Should you receive a denial of service that you do not agree with, you may request a redetermination of the claim. Regardless of physician type or specialty, when requesting redetermination documentation must be submitted.
These guidelines are available on the CMS website, Publication 100-04 (PDF, 482 KB), Medicare Claims Processing Manual, Chapter 13, Section 100.1.
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Last Updated: 05/21/2020