California Medical Bill Reviewer Certification - PowerPoint Presentation

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