CMS Pub. 100-04, ch. 13, § 100.1

The professional component of a diagnostic procedure furnished to a beneficiary in a

hospital includes an interpretation and written report for inclusion in the beneficiary’s

medical record maintained by the hospital. (See 42 CFR 415.120(a).)

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 A/B MACs (B) receive only one claim for an interpretation, they must presume

that the one service billed was a service to the individual beneficiary rather than a quality

control measure and pay the claim if it otherwise meets any applicable reasonable and

necessary test.

When A/B MACs (B) receive multiple claims for the same interpretation, they must

generally pay for the first bill received. A/B MACs (B) must pay for the interpretation

and report that directly contributed to the diagnosis and treatment of the individual

patient. 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 (B) 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. The following examples apply to A/B MACs (B):

EXAMPLE A:

A physician sees a beneficiary in the ER on January 1 and orders a single view chest x-ray. The physician reviews the x-ray, treats, and discharges the beneficiary. An A/B

MAC (B) receives a claim from a radiologist for CPT code 71010-26 indicating an

interpretation with written report with a date of service of January 3. The A/B MAC (B)

will pay the radiologist’s claim as the first bill received. A/B MACs (B) do not have to

develop the claim to determine whether the interpretation was a quality control service.

EXAMPLE B:

Same circumstances as Example A, except that the physician who sees the beneficiary in

the ER also bills for CPT code 71010-26 with a date of service of January 1. The A/B

MAC (B) will pay the first claim received. If the first claim is from the treating physician

in the ER, and there is no indication the claim should not be paid, e.g., no reason to think

that a complete, written interpretation has not been performed, payment of the claim is

appropriate. The A/B MAC (B) will deny a claim subsequently received from a

radiologist for the same interpretation as a quality control service to the hospital rather

than a service to the individual beneficiary.

EXAMPLE C:

Same as Example B except that the claim from the radiologist uses modifier “-77” and

indicates that, while the ER physician’s finding that the patient did not have pneumonia

was correct, there was also a suspicious area of the lung suggesting a tumor that required

further testing. In such situations, the A/B MAC (B) pays for both claims under the fee

schedule.

EXAMPLE D:

The A/B MAC (B) receives separate claims for CPT code 71010-26 from a radiologist

and a physician who treated that patient in the ER, both with a date of service of January

1. The first claim processed in the system is paid and the second claims will be identified

and denied as a duplicate. If the denied “provider” is the radiologist and he raises an

issue the A/B MAC (B) will develop the claim to determine whether the findings of the

radiologist’s interpretation were conveyed to the treating physician (orally or in writing)

in time to contribute to the diagnosis and treatment of the patient. If the radiologist’s

interpretation was furnished in time to serve this purpose, that claim should be paid, and

the claim from the other physician should be denied as not reasonable and necessary.