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Tami Rockholt, RN, BSN
Tami Rockholt, RN, BSN

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Healthcare Fraud and Abuse in Imaging Studies

By Thomas Freedland, DC Healthcare Fraud and Abuse in Imaging Studies 13 May 2014

- Improper billing for diagnostic services remains an ongoing concern. The 70000 series of the AMA’s Current Procedural Terminology (CPT) Codebook covers diagnostic imaging procedures.


By definition the use of these codes includes the performance of the imaging study (taking of x-ray films, performing an MRI scan, etc.) and the clinical interpretation of the study as recorded in a report. In today’s healthcare setting, it is not unusual for a study to be performed at one location and is interpreted by radiologist at a different location. When this happens a modifier is used to better define the basic CPT code.

 

When a CPT code is billed without a modifier it is presumed to include both the production of the study and its interpretation. A three view cervical x-ray study billed with CPT code 72040 tells the payer the charge includes both elements, the production of the study and its interpretation.


If the health professional only produces the image, and does not interpret the study, he should bill using CPT code 72040-TC identifying that only the technical portion was performed at his facility. It implies that the study has been forwarded to another health professional for interpretation.


The radiologist would review the imaging study and produce a report of the clinic findings; he would bill CPT code 72040-26. The “26” modifier identifies the service as the professional interpretation.


The reviewing doctor might use CPT code 76140 (Review of x-rays performed elsewhere) in lieu of appending a modifier. This code is typically used when the review of the diagnostic study is a second opinion, and a prior review (and report) was completed.


There are times when the reviewing doctor is not sure of the clinical importance of something seen when evaluating the study, and a second opinion is requested. In such as case the reviewing doctor would describe his concerns and explain the need for the second review. A charge for this second interpretation would be reasonable and expected using modifier 26 or CPT code 76140.


When reviewing billing records, it is not uncommon to find facilities billing for a diagnostic procedure without appending a modifier when only technical component was performed.

 

This erroneous billing practice can result in a payer reimbursing twice for the interpretation of a diagnostic study.

Both State and Federal regulations define imaging parameters. Studies must be of diagnostic quality; any image not meeting this standard should be repeated. To bill for a diagnostic study that is incomplete (not of diagnostic quality) would amount to seeking payment for a (complete) service that was not performed.

 

Separate reports are required for all diagnostic imaging studies. A copy of the report should be kept with the imaging study. Clinically relevant findings should also be included in the patient’s notes. In addition to describing the need for the study, the notes should address how the results of the diagnostic procedure will change patient management, even if the results do not result in a change in care. A pertinent negative is as clinically important as an abnormal finding.


Diagnostic procedures remain a problem ripe for “accidental” billing errors. Careful review of professional reports, facility charges, and modifiers may prevent payment for duplicate charges.

 

Paying Twice for Imaging Studies

 

As Doctor Freedland points out, forgetting to add modifiers to imaging studies is a big problem. When I speak to claims adjusters in the auto insurance industry, I always emphasize that they may be paying twice for imaging studies as much as 80% of the time. Of all thing things I teach, paying attention to these modifiers is the easiest thing they can do that will make the biggest difference to the bottom line.