Coding specialists frequently receive questions about whether a written report (documentation) is needed to support claims reporting the professional interpretation of X-rays by orthopaedic surgeons.

Typically, an orthopaedic surgeon in private practice owns the radiology equipment, employs the staff and interprets the X-ray. The physician reports radiology services using a global radiology code, such as CPT code 73564 “Radiologic examination, knee; complete, four or more views.” Payment for this code includes both professional and technical components (TC).

If the physician took the X-ray, but did not read it, a TC modifier would need to be appended to the code. Similarly, a modifier 26 would be used with the global CPT code if the doctor read the X-ray but did not take it. The physician may only report the professional interpretation (modifier 26) if the X-ray has not already been interpreted.

In-office X-ray payments

Payment for CPT code 73564 varies depending on whether the physician provides the entire service or a portion of it. For example, using the 2007 transitional RVUs and values, unadjusted for geographic area, a physician would receive:

1. 1.00 RVUs or $37.90 by Medicare, for the entire service (professional and technical component)
2. 0.30 RVUs or $11.37 by Medicare, for the professional component only (73564-26)
3. 0.70 RVUs or $26.53 by Medicare, for the technical component only (73564-TC)

Professional interpretation of X-rays

The CPT rules for the professional interpretation of X-rays are outlined in the radiology section of CPT 2007, as follows:

Written report(s)

A written report, signed by the interpreting physician, should be considered an integral part of a radiologic procedure or interpretation.

The evaluation and management (E/M) documentation guidelines also address the need for a separate written report if the physician is reporting the professional interpretation of X-rays, as follows:

The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with modifier 26 appended.

AMA citation supports the need for proper reporting

The following excerpt from the AMA CPT Assistant (June 2000) “Question and Answer” section reinforces the CPT requirements for a separate written report when reporting the professional interpretation of an X-ray.

Question:

When magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) are performed on the same anatomic region (e.g., head) can both procedures be reported separately?

AMA Comment:

If a separate MRI examination of an anatomic region is performed, and that nonangiographic examination is separately interpreted and a separate report is written, then it may be separately reported in addition to the MRA exam.

What’s new for 2007?

The 2007 CPT Manual includes the following statement regarding written reports:

Results/Testing/Reports

Results are the technical component of a service. Testing leads to results; results lead to interpretation. Reports are the work product of the interpretation of numerous test results.

This further supports a report as a separate document to support the work associated with “interpreting” versus “reviewing” X-rays.

What does Medicare say?

Although a former Medicare physician director stated that the physician’s interpretation may be included within the body of the E/M under a separate header, this instruction is not consistent with AMA CPT Rules, nor is it supported in current instructions or rules in the Medicare Internet Only Manual (IOM). A carrier may base its refund request on a practice’s failure to follow these instructions to dictate a separate report.

The following citations addressing documentation for the professional interpretation of X-rays are found in the Medicare IOM (www.cms.hhs.gov/manuals.pdf). Note that the written report is required to differentiate the work associated with providing a “formal interpretation” of the X-ray from the work associated with a “review” of the X-ray. The work associated with “formal interpretation” requires a written report similar to that report provided by a specialist (radiologist) in that field.

B3 15022

20.1 - Professional Component (PC)

(Rev. 1, 10-01-03)

Carriers must pay for the PC of radiology services furnished by a physician to an individual patient in all settings under the fee schedule for physician services regardless of the specialty of the physician who performs the service. For services furnished to hospital patients, carriers pay only if the services meet the conditions for fee schedule payment and are identifiable, direct, and discrete diagnostic or therapeutic services to an individual patient, such as an interpretation of diagnostic procedures and the PC of therapeutic procedures. The interpretation of a diagnostic procedure includes a written report.

A second source for separate reports may be found in section 100 of the Radiology Billing Manual; the latest revisions for these instructions are from 2003. The following excerpt specifically addresses X-rays in the emergency room, but the requirements are the same when the physician wishes to report services for the professional interpretation. This citation also specifies who may report the services and that Medicare will reimburse the first claim submitted.

B3-15023

100.1 - X-rays and EKGs Furnished to Emergency Room Patients

(Rev. 1, 10-01-03)

The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary’s medical record maintained by the hospital. (See 42 CFR 415.120(a).)

Carriers generally distinguish between an “interpretation and report” of an X-ray or an EKG procedure and a “review” of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment. For example, a notation in the medical records saying “fx-tibia” or “EKG-normal” would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An “interpretation and report” should address the findings, relevant clinical issues, and comparative data (when available).

Generally, carriers must pay for only one interpretation of an EKG or X-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier “77”) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.

When carriers receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.

When carriers receive multiple claims for the same interpretation, they must generally pay for the first bill received.

Summary

Both CPT rules and Medicare billing/payment rules address the need for a separate written report with Medicare, further stating the report should mirror a report by a specialist in the field.

Determine the best method in your practice for achieving this documentation requirement. Ensure your documentation includes specific views (e.g. PA/lateral, standing), anatomic location of X-ray, diagnosis, reason for X-ray and professional interpretation.

Action Steps

4. If you dictate your X-ray interpretation in the body of the note, request that your transcriptionist copy and paste it to a reports page under the Radiology tab. Remember, the interpretation must include views, anatomic location, diagnosis, reason for X-ray and interpretation.
5. If you are using an electronic health record (EHR), work with your vendor to create a section within your E/M that allows for X-ray interpretation to be included within the body of the E/M note and then electronically hyperlinks to a separate Radiology section as a separate report. This feature can easily be set up within EHR systems.
6. Remember, all information related to the ordering of the X-rays, anatomic views, location, and interpretation must be within the body of the E/M note to receive “credit” for the medical decision making.
7. Sign both the E/M note and the separate interpretation. If signatures can be created electronically, the responsibility is the provider’s—do not delegate this task to staff!

Mary LeGraud, RN, MA, CCS-P, CPC, is a coding specialist with Karen Zupko and Associates.