How to Code and Bill Diagnostic Tests

Interpretation of Diagnostic Tests

In order to report the professional component or the global procedure, the question arises, does the physician interpreting the test document a separate report?

CPT states, “A written report signed by the interpreting physician, should be considered an integral part of a radiologic procedure or interpretation.” The E/M documentation guidelines identify the requirement for a separate written report for the professional interpretation. The guidelines are as follows:

“The actual performance and/or interpretation of diagnostic test/studies ordered during a patient encounter are not included in the levels of Evaluation and Management (E/M) services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separately distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code.” If only the professional component is reported, modifier 26 is added to the CPT code.

In order to report the professional and technical component of a diagnostic X-ray or test, four issues must be addressed:

1. The X-ray or test is performed in the facility.

2. An examination is documented (X-ray is read and interpreted).

3. A written report supports documentation requirements.

4. A report similar to what a radiologist will report to meet the scope of service requirements.

Keep in mind that results are the technical component of the service. Testing leads to results, results lead to interpretation, and the report is the work product of the interpretation.

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]