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

2 Arizona Regulation Training-Radiology Overview Hi! 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 Well 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 Arizona Regulation Training-Radiology 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

4 Arizona Regulation Training-Radiology Radiological Services Radiological services consist of two components, which are often performed by different providers. Professional ComponentTechnical Component Lets take a look…

5 Arizona Regulation Training-Radiology Radiology The professional component of service includes the physicians services. Professional Component Professional services include: Examining a patient. Conducting or supervising a procedure. Interpreting and documenting, in a written report, the examination & consultation with the referring physician.

6 Arizona Regulation Training-Radiology 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 cant be billed.

7 Arizona Regulation Training-Radiology Technical Component The technical component of service includes all other charges not related to the value of the physicians services. The technical component excludes the cost of radioisotopes and non-ionic contrast media. Technical Component Technical services include: Personnel (technicians) Contrast media & drugs Film & xerography Space, equipment, and other facilities.

8 Arizona Regulation Training-Radiology 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 Arizona Regulation Training-Radiology X-ray Consultations Now that you are familiar with some basics of radiology, lets discuss how other radiological services are reimbursed. Radiology Guidelines Types of Radiology Services X-ray Consultations Review of Diagnostic Services X-ray Consultations Lets start by discussing how x-ray consultations are reimbursed...

10 Arizona Regulation Training-Radiology X-ray Consultations Just like other services, physicians often provide consultation services regarding x-ray results. The review of x-ray results is included in the E&M codes. When a charge is submitted for a physicians interpretation and report on radiology procedure, or other professional services related to that procedure, as designated with modifier 26, the maximum medical reimbursement will be that listed in the PC AMOUNT column of the fee schedule. Hi...yes, I have looked at the results and immediate surgery is required.

11 Arizona Regulation Training-Radiology Therefore, under these circumstances, CPT should be denied. X-ray Consultations Be aware that providers often mistakenly use CPT Providers incorrectly bill 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 is not allowed for routine x- ray reviews. Lets take a look…

12 Arizona Regulation Training-Radiology If the primary treating physician reviews an x-ray to make a diagnosis as part of an initial evaluation, CPT is not reimbursable. X-ray Consultations Example: Non-Reimbursable Yep, just as I suspected... its a fracture. Yes, Mrs. Jones, I took a look at the x-ray, and your arm is broken.

13 Arizona Regulation Training-Radiology 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 a patient evaluation. This is because the review of diagnostic tests is included in Evaluation and Management codes.

14 Arizona Regulation Training-Radiology Radiology Reimbursement 1.For two contiguous (next/near) parts, the charge shall be the greater fee plus 50% of the lesser fee. 2.For two remote (separated) parts, the charge shall be the greater fee plus 75% of the lesser fee. Bilateral procedures are considered remote parts. 3.For three or more parts, whether contiguous or remote, the charge shall be the greatest fee plus 75% of the total of the lesser fees. The system is automated. Key as billed. Radiology Multiple Cutback Rule

15 Arizona Regulation Training-Radiology Radiology Reimbursement When multiple x-ray exams are made at the same visit and without concomitant other services, values for each exam except the major exam will be reduced by: $1.715 for Professional Component $8.73 for Total Services The system is automated. Key as billed. Definition: Concomitant – Existing or occurring concurrently Radiology Concomitant Rule

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