1. Provided by Coventry Health Care Texas Medical Bill Reviewer Training Program Unit 1: Professional Services Module 4: Radiology ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.

2. Texas Regulations Training August 2011 2 Overview In this module, you will learn about radiology guidelines and the different types of radiological services.  Radiology Guidelines  Types of Radiology Services  X-ray Consultations  Review of Diagnostic Services  Radiology Guidelines  Types of Radiology Services We’ll start by discussing some general guidelines as well as the different types of radiology services. Then, you will learn how X-ray consultations and reviews are reimbursed.

3. Texas Regulations Training August 2011 3 Radiology Guidelines Radiology is the branch of medicine that provides diagnostic and treatment services using radiation and various imaging techniques. Radiological services include:  Diagnostic Radiology  Diagnostic Ultrasound  Radiation Oncology  Nuclear Medicine The radiology section ranges from 70010-79999.

4. Texas Regulations Training August 2011 4 Radiological Services Radiological services consist of two components, which are often performed by different providers. Professional ComponentTechnical Component

5. Texas Regulations Training August 2011 5 Radiology The professional component of service includes the physician’s services. Professional Component Professional services include:  Examining a patient.  Conducting or supervising a procedure.  Interpreting and documenting, in a written report, the examination and consultation with the referring physician.

6. Texas Regulations Training August 2011 6 Radiology For example, if an Emergency Room physician reads a film to determine a diagnosis and treatment, this is NOT a radiology charge. If there is no formal interpretation and written report, the professional component can’t be billed.

7. Texas Regulations Training August 2011 7 Technical Component The technical component of service includes all other charges not related to the value of the physician’s services. The technical component excludes the cost of radioisotopes and non-ionic contrast media. Technical Component Technical services include:  Personnel (i.e. technicians)  Contrast media and drugs  Film and xerography  Space, equipment and other facilities.

8. Texas Regulations Training August 2011 8 Global Service When a radiological procedure includes both a professional and technical component, it constitutes a global service. For instance, a procedure is considered a global service when the same provider performs both the professional and technical components. I will review the x- rays and let you know what they show.

9. Texas Regulations Training August 2011 9 X-Ray Consultations Now that you are familiar with some basics of radiology, let’s discuss how other radiological services are reimbursed. Radiology Guidelines Types of Radiology Services  X-Ray Consultations  Review of Diagnostic Services  X-Ray Consultations Let’s start by discussing how consultations are reimbursed.

10. Texas Regulations Training August 2011 10 X-Ray Consultations Just like other services, physicians often provide consultation services regarding x-ray results. The review of the x-ray results is included in the E&M codes. Hi... yes, I have looked at the results and immediate surgery is required.

11. Texas Regulations Training August 2011 11 Therefore, under these circumstances, CPT 76140 should be denied. X-Ray Consultations Be aware that providers often mistakenly use CPT 76140. Providers incorrectly bill 76140 when:  They perform an initial review of records that include the radiological report or actual x-ray film.  They perform a routine review of x-ray films. Reimbursement of CPT 76140 is not allowed for routine x- ray reviews.

12. Texas Regulations Training August 2011 12 If the primary treating physician reviews an X-Ray to make a diagnosis as part of an initial evaluation, CPT 76140 is not reimbursable. X-Ray Consultations Example: Non-Reimbursable Yep, just as I suspected; it’s a fracture. Yes, Mrs. Jones, I took a look at the x-ray, and your arm is broken.

13. Texas Regulations Training August 2011 13 Review of Diagnostic Studies As you just saw, physicians often review x-ray results with their patients. To recap, this service is not reimbursable when it is performed during a patient consultation review of records or patient evaluation. This is because the review of diagnostic tests is included in Evaluation and Management codes.

14. Texas Regulations Training August 2011 14 Fluoroscopic Procedures Fluoroscopy is a type of medical imaging that shows a continuous x-ray image on a monitor, much like an x-ray movie. When fluoroscopic procedures 76005 and 77003 are billed with surgery procedures 64470-64484, they are not reimbursable for more than one unit of service. The system will deny with M105. When a bill in history has been paid for more than one fluoroscopic procedure and a current bill contains any surgery procedure codes 64470-64484, an edit will set with manual pricing instructions.

15. Texas Regulations Training August 2011 15 Radiology Reimbursement Key all other radiology procedure codes and charges as billed. The system is automated to recommend the appropriate payment.

16. Texas Regulations Training August 2011 16 Summary How professional and technical components differ How x-ray consultations are reimbursed How review of diagnostic studies are reimbursed Radiology: Guidelines and Services