How to Code and Bill Diagnostic Tests

Example: patient visits the ABC Urgent Care Center with congestion, fever and symptoms of pneumonia. The urgent care physician decides to order a PA (posterior anterior) and lateral chest to rule out pneumonia. The physician’s X-ray tech performs the X-ray and the physician documents the interpretation. The X-ray confirms the patient has pneumonia. How would the service be reported?

Code 71020 for PA and lateral chest is the appropriate choice. Since the physician performed the X-ray in the facility, and supervised and interpreted the X-ray, the global code is reported without a modifier.

Another important consideration is the diagnosis code. In this example, there is a confirmed diagnosis of pneumonia. If the physician has a confirmed diagnosis based on the results of the diagnostic test (71020), the physician interpreting the test/X-ray should report the confirmed diagnosis. The signs and/or symptoms that prompted ordering the X-ray may be reported as additional diagnoses if they are not fully explained or are not related to the confirmed diagnosis. However, in the example above, the signs and symptoms are related and would not be required on the claim, even though the physician should make certain they are documented to support medical necessity.

If the physician takes the X-ray, but does not read it, modifier TC would be appended to the global code. Similarly, a modifier 26 would be appended to the code if the physician read and interpreted the X-ray but did not take it. The physician may report the X-ray code with modifier 26 if and only if the X-ray has not already been interpreted.

If the physician provides an evaluation and management (E/M) service during the patient encounter, the guidelines address the need for a separate written report. This is if the physician is reporting the interpretation of the X-ray, whether the global service is reported (71020) or the professional component of the service (71020-26) is reported.

Example: A patient visits the ABC Urgent Care Center with shortness of breath, congestion, and cough. Based on examination of the patient, the physician decides to order a PA and lateral chest X-ray to rule out pneumonia. The technician performs the X-ray and the physician gives the X-ray to the radiologist who comes in to read X-rays on the weekend to interpret results. The radiologist does not work for the urgent care center, and bills the urgent care center for the radiology services. The radiologist reads the films and determines the patient does not have pneumonia, but discovers a 3-centimeter peripheral nodule. The encounter is reported as follows:

Urgent care physician: 71020-TC

Radiologist: 71020-26

In this case, the urgent care center would report only the technical component since the radiologist is not employed by the facility and is independent in interpreting the X-ray. Since the diagnosis of peripheral nodule is confirmed, it should be reported as the first-listed diagnosis with cough that is a sign/symptom reported as a secondary diagnosis (reason for the X-ray).

Payment for X-ray procedures varies depending on whether the urgent care physician provides the entire service or a portion of the services. For example, when using the relative value units (RVUs) unadjusted for the geographic area, using the National Fee Schedule, the urgent care center would receive for X-ray services for example a Medicare patient:

Payment RVU Procedure

$33.¹⁴ 0.⁸⁷ 71020 (global procedure)

$22.⁸⁵ 0.⁶⁰ 71020-TC (technical component)

$10.²⁸ 0.²⁷ 71026-26 (professional component)

Share this article: Email, Slashdot, Digg, Del.icio.us, Yahoo!MyWeb, Windows Live Favorites, Furl
Add this article feed to: RSS, My Yahoo, Newsgator, Bloglines

Read Comments [0]