Radiology is a medical specialty in which practitioners do not always see the patient directly. Like any medical doctor, a radiologist can conduct physical exams and perform face-to-face consultations, but their professional skill lies in using sophisticated imaging technology to diagnosis disease. Radiology billing is different from other kinds of medical billing.
An outpatient radiology practice interacts with patients in a number of ways. The radiologist will examine the patient, usually by referral from another M.D. After determining that a radiological exam is warranted, the patient will undergo the procedure. The results are then interpreted by the radiologist in order to render a report of the findings and a diagnosis. Interventional radiology adds another wrinkle to the services offered by radiology practice. Invasive medical procedures can be performed under radiological guidance. There are codes for that, and accurate radiology coding is the backbone of radiology billing.
Because much of the expense in performing radiology examinations lies in the operation of sophisticated equipment, the procedure codes used to report radiology services for reimbursement are composed of a technical component and a professional component. These two parts of a procedure can be reported together, or they may need to be reported separately.
The technical component of a radiology code is reported on a healthcare claim when the procedure is performed but it is not interpreted by a staff radiologist. Common Procedure Terminology (CPT) codes used for radiology billing assume that the rendering physician performs or oversees a procedure and provides medically useful information based on the results. A radiology practice cannot bill for an interpretation of a test’s results if a professional diagnosis has not been rendered. This is why radiology CPT codes are split into technical and professional components.
Many radiology practices perform radiological exams for ordering physicians that those physicians choose to read themselves. A certified radiology technician prepares the equipment, preps the patient, performs the exam, and generates the report. If that report is sent directly to the ordering physician without radiologist review, there is no professional component for the service. Medically necessary services have been supplied by the radiology practice, but it cannot bill for what it did not do.
Through the use of appropriate modifiers, professional and certified radiology coders and billers can recoup appropriate reimbursement for these services. The payment is not as high as that for the service with professional interpretation, but it covers the cost of providing the service with room for profit.
If a radiologist is sent test results that have not yet been reviewed by a fellow physician, he or she cannot bill for the entire procedure, but the professional component can and should be billed. By modifying applicable CPT codes, radiology billers can capture legal reimbursement for the physician work needed to establish a diagnosis and contribute to the patient’s treatment plan.
The appropriate use of justified modifiers is an essential component of accurate radiology billing. Modifiers -25, -26, and PC are of particular concern. In the case of an audit by an insurer, the medical documentation must support the use of modifiers to CPT codes. RAC audits, which are being used by the Medicare program to detect cases of billing fraud and abuse, rely on documentation to substantiate charges of improper payments. Professional medical coders and billers are expert in the use of modifiers used according to individual payer guidelines. They can perform pre-payment internal audits to ensure that clean claims are submitted for payment.
Medical necessity is proven on a healthcare claim by using appropriate diagnosis codes. ICD-9-CM and ICD-10 are the systems used to report medical diagnoses. Both systems mandate that “rule-out” conditions cannot be coded. A radiology practice often receives requisitions that contain only a rule-out diagnoses. A medical documentation specialist can review the patient’s record to assign the appropriate code to justify timely reimbursement.