Billing and Coding Article

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

A53423

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11202 - MAC B	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11302 - MAC B	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11402 - MAC B	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11502 - MAC B	J - M	North Carolina

Article Information

General Information

Article ID
A53423

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

Article Type
Billing and Coding

Original Effective Date
10/01/2015

Revision Effective Date
10/10/2019

Revision Ending Date
N/A

Retirement Date
N/A

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CMS National Coverage Policy

CMS-Internet Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1.

Article Guidance

Article Text

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.

Response To Comments

Number	Comment	Response
1

Coding Information

CPT/HCPCS Codes

N/A

CPT/HCPCS Modifiers

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Group 1

(2 Codes)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
76	REPEAT PROCEDURE BY SAME PHYSICIAN: THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS REPEATED SUBSEQUENT TO THE ORIGINAL PROCEDURE OR SERVICE. THIS CIRCUMSTANCE MAY BE REPORTED BY ADDING THE MODIFIER -76 TO THE REPEATED PROCEDURE OR SERVICE OR THE SEPARATE FIVE DIGIT MODIFIER CODE 09976 MAY BE USED.
77	REPEAT PROCEDURE BY ANOTHER PHYSICIAN: THE PHYSICIAN MAY NEED TO INDICATE THAT A BASIC PROCEDURE OR SERVICE PERFORMED BY ANOTHER PHYSICIAN HAD TO BE REPEATED. THIS SITUATION MAY BE REPORTED BY ADDING MODIFIER -77 TO THE REPEATED PROCEDURE/SERVICE OR THE SEPARATE FIVE DIGIT MODIFIER CODE 09977 MAY BE USED.

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
10/10/2019	R9	This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual. CMS-Internet Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1 has been added to the *CMS National Coverage Policy* section. Under *Article Title* changed title from “Repeat X-ray or EKG Interpretations by Same or Different Physician” to “Billing and Coding: Repeat X-ray or EKG Interpretations by Same or Different Physician”. Under *CPT/HCPCS Modifiers* added modifiers 76 and 77.
07/05/2018	R8	Under *Article Text*, changed the word “submitted” to “billed” in the third bullet. Punctuation was corrected throughout the article.
02/26/2018	R7	The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
07/14/2016	R6	Annual validation with no revisions made.
07/14/2016	R5	Under *Article Text* added the statement 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. The word “website” was deleted and the verbiage “Internet-Only Manual” was added in the last sentence. Under *Associated Documents-Statutory Requirements URL(s)* the URL “Title XVIII of the Social Security Act §1862(a)(1)(A)” was deleted.
05/19/2016	R4	Removed the link from *CMS Manual Explanations URL(s)*.
10/01/2015	R3	Under *Associated Documents* added Title XVIII of the Social Security Act §1862(a)(1)(A).
10/01/2015	R2	Added CMS Internet-Only Manual Citation from the Article Text to the Associated Documents.
10/01/2015	R1	Added Medicare Contractor Numbers

Associated Documents

Updated On	Effective Dates	Status
09/30/2019	10/10/2019 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

X-ray
EKG Interpretations

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

Document Note

Note History

Contractor Information

Article Information

General Information

CMS National Coverage Policy

Article Guidance

Response To Comments

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

ICD-10-PCS Codes

Group 1

Additional ICD-10 Information

Bill Type Codes

Revenue Codes

Other Coding Information

Group 1

Coding Table Information

Revision History Information

Associated Documents

Keywords

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