Unit 2 Official Medical Fee Schedule Module 6 Radiology Overview Hi In this module you will learn about radiology guidelines and the different types of radiological services Then you will learn about modifiers as well as how things like xray consultations and reviews are reimbursed ID: 684581
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Slide1
California Medical Bill Reviewer Certification
Unit 2: Official Medical
Fee Schedule
Module 6: RadiologySlide2
Overview
Hi! In this module, you will learn about radiology guidelines and the different types of radiological services.
Then, you will learn about modifiers, as well as how things like x-ray consultations and reviews are reimbursed.
Radiology Guidelines
Types of Radiology Services
Modifiers:
26
27
X-ray Consultations
Review of Diagnostic Services
X-ray Duplications
We’ll start by discussing some general guidelines as well as the different types of radiology services.Slide3
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
In the OMFS, the surgery section ranges from
70010-79999
.Slide4
Radiological Services
Radiological services consist of two components, which are often performed by
different
providers.
Professional Component
Technical ComponentSlide5
Professional Component
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 & consultation with the referring physician.Slide6
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 & drugs
Film & xerography
Space, equipment, and other facilities.Slide7
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 send a report to your treating physician.Slide8
Radiology Reimbursement
The listed
value
for radiology codes contains both the professional and the technical component.
When billed separately, reimbursement is calculated by using the appropriate percentage listed in the fee schedule under the professional (PC) or technical (TC) component.
But, professional and technical components can be billed
separately
.
In no event should reimbursement for both components
exceed
the cost of the total listed value
.Slide9
Modifiers
You might be wondering how to tell whether a bill is for a professional or technical component of a single service.Slide10
Modifier 26
Specific
modifiers
indicate when professional and technical components for a single service are billed separately.
26 Professional Component:
This modifier
indicates when the professional
, or physician’s component, of the procedure is reported separately from the technical component.Slide11
Modifier 27
As you might have guessed, there is a specific modifier that indicates the technical component of a radiological procedure.
27 Technical Component:
This modifier
indicates when the
technical
component of the procedure is reported separately from the professional component.Slide12
Why might this be?
Modifier 27
When a radiological procedure is billed by a hospital, you can almost guarantee that it is for the
technical component
regardless if
modifier 27
is not present.
Be certain to check history for the
professional component billed by a radiological group.
Remember, the technical component includes facility charges.Slide13
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
Modifiers:
26
27
X-ray Consultations
Review of Diagnostic Services
X-ray Duplications
Let’s start by discussing how x-ray consultations are reimbursed...Slide14
X-ray Consultations
Just like other services, physicians often provide consultation services regarding x-ray results.
CPT 76140: X-ray consultation
is only reimbursable when the
advice
or
expert opinion
of a physician is requested regarding a specific diagnostic problem.
Hi...yes, I have looked at the results and immediate surgery is required. Slide15
X-ray Consultations
You should recall from your studies of Evaluation and Management that when a physician provides an opinion or gives advice, it is considered a
consultation
service.
Remember that evaluation and management services, which typically include the initial review and diagnosis,
differ
from consultations.
CPT 76140
can only be billed by a physician who provides a
second opinion
, not one who reviews the x-rays during an initial evaluation.Slide16
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.
Let’s take a look…Slide17
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 you arm is broken.Slide18
X-ray Consultations
Example:
Reimbursable
However, if a physician is asked to review an x-ray or scan to provide a second opinion,
CPT 76140
is
reimbursable
.
Yes, I see what you mean. I agree...schedule the patient for an operation. Good work, Dr. Allan.Slide19
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.Slide20
X-ray Duplication
Sometimes, radiographs or scans must be
duplicated
.
In these instances, providers bill
CPT 76175
and/or CPT 76176.
Duplication Cost:
$5.00 per x-ray
$10.00 per scan sheetSlide21
Summary
How professional and technical components differ.
Modifiers: Common modifiers in radiology.
How x-ray consultations are reimbursed.
How review of diagnostic studies are reimbursed.
Radiology: Guidelines and Services.
How duplications of films and scans are reimbursed.Slide22
Module Quiz
It’s time to check your knowledge of the concepts presented in this module.
This quiz is scored.
You must achieve a score of 80% to pass. You may attempt this quiz as many times as needed to achieve a passing score.
When finished, you may move on to the next module.Slide23
CA MBR Unit 2 Module 6 Quiz