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

2. 2 Illinois Regulation Training - Radiology July 2011 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. 3 Illinois Regulation Training - Radiology July 2011 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. 4 Illinois Regulation Training - Radiology July 2011 Radiological Services Radiological services consist of two components, which are often performed by different providers. Professional ComponentTechnical Component Lets take a look…

5. 5 Illinois Regulation Training - Radiology July 2011 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. 6 Illinois Regulation Training - Radiology July 2011 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. 7 Illinois Regulation Training - Radiology July 2011 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 (i.e. technicians) Contrast media & drugs Film & xerography Space, equipment, and other facilities.

8. 8 Illinois Regulation Training - Radiology July 2011 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. 9 Illinois Regulation Training - Radiology July 2011 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. 10 Illinois Regulation Training - Radiology July 2011 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. 11 Illinois Regulation Training - Radiology July 2011 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. Lets take a look…

12. 12 Illinois Regulation Training - Radiology July 2011 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... its a fracture. Yes, Mrs. Jones, I took a look at the x-ray, and your arm is broken.

13. 13 Illinois Regulation Training - Radiology July 2011 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. 14 Illinois Regulation Training - Radiology July 2011 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. 15 Illinois Regulation Training - Radiology July 2011 Summary How professional and technical components differ. How x-ray consultations are reimbursed. How review of diagnostic studies are reimbursed. Radiology: Guidelines and Services.