“We have a disagreement among our group regarding radiology billing. If a new patient presents with x-rays, MRI, etc., from an outside source, without a report (or with an inadequate report), can the podiatrist bill for the professional component of reading the imaging studies provided?”
X-rays can only be read, interpreted, and billed for one time. By the time a patient brings you a set of X-rays from another source the service has already been paid. So, what can be done? Even if you were able to bill for the professional component for reading and interpreting another physician’s X-rays, think about what you get paid for the Global X-ray Reimbursement when you, as the treating physician obtain and interpret a patient’s X-rays in your office. Isn’t it about $25.00-$30.00? The Technical Component makes up approximately 2/3 of the reimbursement and the Professional Component makes up the remaining 1/3. So, the best-case scenario would be that if you were able to bill for the Professional Component for reading and interpreting another physician’s X-rays, you are looking at somewhere between $8.33 – $10.00. Not so great.
However, thank goodness that we have E/M services. As part of the E/M service, assuming that you are using Medical Decision Making (MDM) to determine the level of E/M service, you may have the option of either billing a 99202 or perhaps a 99203 based upon the medical record documentation and of course the Elements of Medical Decision Making.
As I have opined previously, there are three Elements of Medical Decision Making. The three elements are Number and Complexity of Problems, Amount and/or Complexity of Data to be Reviewed and Analyzed, and Risk of Complications and/or Morbidity or Mortality of Patient Management. Two out of the three elements need to be performed and documented in the medical record to achieve the appropriate level of E/M service. Of course, a medically appropriate history and/or examination would have to be performed as well.
E/M code 99202 requires a Straightforward Level MDM:
The Number and Complexity of Problems Addressed are Minimal:
1 self-limited or minor problem
The Amount and/or Complexity of Data to be Reviewed and Analyzed:
Minimal or none
The Risk of Complications and/or Morbidity or Mortality of Patient Management:
Minimal risk of morbidity from additional diagnostic testing or treatment
How hard is it to achieve E/M 99202? You are reading another physician’s X-rays and generating a report. E/M 99202 reimburses approximately $75!
E/M code 99203 requires a Low Level of MDM:
The Number and Complexity of Problems Addressed is Low:
2 or more self-limited or minor problems; or
1 stable chronic illness; or
1 acute, uncomplicated illness or injury
The Amount and/or Complexity of Data to be Reviewed and Analyzed is Limited:
(Must meet the requirements of at least 1 of the 2 categories)
Category 1: Tests and documents
Any combination of 2 from the following:
• Review of prior external note(s) from each unique source*
• review of the result(s) of each unique test*
• ordering of each unique test*
OR
Category 2: Assessment requiring an independent historian(s)
The Risk of Complications and/or Morbidity or Mortality of Patient Management:
Low risk of morbidity from additional diagnostic testing or treatment
Obviously, it is more difficult to achieve an E/M 99203. You cannot justify billing an E/M 99203 by reading another physician’s X-rays and generating a report.
The question in the above post was related to the billing for the professional component of reading another physician’s imaging studies for a new patient. Clearly aside from the fact that it is not a billable entity, if it was billable the reimbursement is awful. However, by supporting the billing of E/M code 99202 with a medically appropriate history and/or examination and the correct level of Medical Decision Making, the reimbursement for the encounter certainly makes much more sense.
Source of information: Elements of Medical Decision Making Table.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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