Provided by Coventry Health Care Texas Medical Bill Reviewer Training Program Unit 1: Professional Services Module 4: Radiology ©2011 Coventry Health Care.

Provided by Coventry Health Care

Texas Medical Bill Reviewer Training Program

Unit 1: Professional Services

Module 4: Radiology

©2011 Coventry Health Care. All rights reserved.Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.

Texas Regulations TrainingAugust 2011

2

OverviewIn 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

We’ll 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

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

Radiological Services

Radiological services consist of two components, which are often performed by different providers.

Professional

ComponentTechnical Component


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Radiology

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 and consultation with the referring physician.


6

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 can’t be billed.


7

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 and drugs Film and xerography Space, equipment and other

facilities.


8

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

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 X-Ray Consultations Review of Diagnostic Services X-Ray Consultations

Let’s start by discussing how

consultations are reimbursed.


10

X-Ray Consultations

Just like other services, physicians often provide consultation services regarding x-ray results.

The review of the x-ray results is included in the E&M codes.

Hi . .. yes, I have looked at the results and

immediate surgery is required.


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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.


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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 your arm is

broken.


13

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 patient evaluation.

This is because the review of diagnostic tests is included in Evaluation and Management codes.


14

Fluoroscopic Procedures

• Fluoroscopy is a type of medical imaging that shows a continuous x-ray image on a monitor, much like an x-ray movie.

• When fluoroscopic procedures 76005 and 77003 are billed with surgery procedures 64470-64484, they are not reimbursable for more than one unit of service. The system will deny with M105.

• When a bill in history has been paid for more than one fluoroscopic procedure and a current bill contains any surgery procedure codes 64470-64484, an edit will set with manual pricing instructions.


15

Radiology Reimbursement

Key all other radiology procedure codes and charges as billed.

The system is automated to recommend the appropriate payment.


16

Summary

How professional and technical components differ

How x-ray consultations are reimbursed

How review of diagnostic studies are reimbursed

Radiology: Guidelines and Services

Provided by Coventry Health Care Texas Medical Bill Reviewer Training Program Unit 1: Professional Services Module 4: Radiology ©2011 Coventry Health Care.

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texas regulations training

radiology guidelines

physicians services

consultation services

treatment services

xray results

professional services

xray consultations example