Billing and Coding: Repeat X-ray or EKG Interpretations by Same or Different
Physician

CMS National Coverage Policy Language quoted from the Centers for Medicare and
Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage
provisions in interpretive manuals is italicized throughout the article.  
  
_A/B MACs (B) 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, A/B MACs (B) 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 only one claim for an interpretation is received, it must be presumed
that the one service submitted was a service to the individual beneficiary
rather than a quality control measure. The claim may be paid if it otherwise
meets any applicable reasonable and necessary test.  
  
When multiple claims for the same interpretation are received, payment for the
first claim received is generally made. Payment for the interpretation and
report that directly contributed to the diagnosis and treatment of the
individual patient is generally made.  
  
 _Consideration is not given to physician specialty as the primary factor in
deciding which interpretation and report to pay regardless of when the service
is performed.  
  
 Consideration is not given to designation as the hospital's 'official
interpretation' as a factor in determining which claim to pay.  
  
 A/B MACs pay for the interpretation billed by the cardiologist or
radiologist if the interpretation of the procedure is performed at the same
time as the diagnosis and treatment of the beneficiary. (This interpretation
may be an oral report to the treating physician that will be written at a
later time.)  
  
If the first claim received is from a radiologist, A/B MACs (B) generally pay
the claim because they would not know in advance that a second claim would be
forthcoming. When A/B MACs (B) receive the claim from the emergency room (ER)
physician and can identify that the two claims are for the same
interpretation, they must determine whether the claim from the ER physician
was the interpretation that contributed to the diagnosis and treatment of the
patient and, if so, they pay that claim. In such cases, A/B MACs (B) must
determine that the radiologist's claim was actually quality control and
institute recovery action.  
  
The two parties should reach an accommodation about who should bill for these
interpretations._  
  
 **Claim Submission Instructions**  
For claims submitted electronically, the unusual circumstances must be
submitted in the appropriate documentation record. Failure to use CPT modifier
77 and submit the necessary documentation will result in denial of the
service. Limitations of liability and refund requirements apply.  
  
 **Repeat Procedures by Same Physician**  
When the same physician interprets serial x-rays or EKGs performed on the same
day, CPT modifier 76 must be submitted to indicate the service was repeated
subsequent to the original procedure.  
  
These guidelines are available on the CMS-Internet Only Manual, Pub 100-04,
Medicare Claims Processing Manual, Chapter 13, Section 100.1.