Author Topic: RADIOLOGY ULTRASOUND  (Read 7661 times)

mtlopez

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RADIOLOGY ULTRASOUND
« on: May 24, 2013, 08:05:03 PM »
 ANYONE KNOW HOW TO GET PAID FOR RADIOLOGY ULTRASOUNDS FOR PCP, DOES THE PCP REQUIERED A RADIOLOGY.  HORIZON BLUE CROSS BLUE SHIELD SAID THAT HE IS NOT ALLOWED TO DO IT.  PLEASE HELP ME.

RichardP

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Re: RADIOLOGY ULTRASOUND
« Reply #1 on: May 24, 2013, 09:05:12 PM »
I assume PCP = Primary Care Physician.

Medicare has been slowly cracking down on physicians performing services and billing for them outside of their specialty.  One of the first areas that attracted their attention was radiology.  A radiologist is highly trained in the art and science of reading pictures.  PCPs, not so much.  Medicare would like to stop physicians from obtaining ultrasound and x-ray machines and performing services with them and billing for both the professional and technical components.  Medicare's position is that radiologists are radiologists, physicians are not, and pictures should be read by radiologists.  So perhaps you are getting caught up in some of this activity spreading out to the commercial carriers.  Each carrier would have their own rules on this.

In any case, make certain that you have the appropriate modifies that indicate whether you are billing for the PC - professional component or TC - technical component, or both.  Also, make certain that you have modifiers if appropriate that indicate location RT, LT, etc. on bilateral procedures.

You might tell us what you are actually billing that is being rejected - what is the procedure + procedure code(s), diagnosis code(s) and modifiers, if any.

mtlopez

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Re: RADIOLOGY ULTRASOUND
« Reply #2 on: May 25, 2013, 12:30:55 PM »
WE ARE USING 76536 (THYROID US), 76700 (US ABDOMINAL), 76770 RETROPERITENEAL COMPLETED.

WE ARE NOT USING MODIFIERS, WE DO NOT HAVE PROBLEMS WITH MEDICARE.  ONLY WITH HORIZON BLUE CROSS BLUE SHIELD AND OXFORD.  THEY DENIED BECAUSE DOCTOR SPECIALTY, AND THE ALSO SAID HE IS NOT ALLOWED TO DOIT.


THANKS

RichardP

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Re: RADIOLOGY ULTRASOUND
« Reply #3 on: May 25, 2013, 03:25:56 PM »
WE ARE NOT USING MODIFIERS

It is my understanding that all radiology has several parts for billing: who took the picture, who interpreted the picture, and who implemented a procedure based on the results of the read.  This translates into what the technician did who took and/or read the pictures (the Technical Component), and what the doctor did based on the reading and interpretation of the pictures (Professional Component) .  It is my understanding that radiology charges must have the PC or TC designation attached to them.  Are you doing this?  Note that if your doctor is taking the picture, reading the picture, and implementing a procedure(s) based on the results of the read, you need to bill for both the TC and PC components.  But that doesn't mean the insurance carrier will pay for either component charge.  See my next point below.

THEY DENIED BECAUSE DOCTOR SPECIALTY, AND THE ALSO SAID HE IS NOT ALLOWED TO DOIT.

I don't know your level of knowledge, but it sounds like you could benefit from reading through the following link, plus the link that I include there.  See if that reading sheds some light on the doctor specialty issue.  If you can, get your doctor's taxonomy number before you start reading.



http://www.medicalbillinglive.com/members/index.php?topic=7072.msg21201#msg21201

Billergirlnyc

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Re: RADIOLOGY ULTRASOUND
« Reply #4 on: May 29, 2013, 07:01:15 PM »
Horizon BCBS of NJ has a whole list of who they allow to do certain radiology/diagnostic imaging services based on specialty etc and they just updated it for 2013 -- the links are below:

http://www.horizonblue.com/sites/default/files/pdf/Priveleging_Policy_05_08_13.pdf
http://www.horizonblue.com/sites/default/files/pdf/PRiv_%2314_04_23_14.pdf - this is the link to look at to see if your doctor is allowed to do the ultrasounds he/she did (from a quick glance doesn't look like it to me) under Horizon BCBS of NJ.

Below is Oxfords policy on Radiology Privileging:
https://www.oxhp.com/brokers/sell/manageyourhealth/radiology_privileging_list.html

We have a ton of patients who have Horizon BCBS of NJ (horrible carrier when it comes to payment, haha) and we bill for Radiology. Horizon (like most commercial carriers) have their own rules regarding this, and short of suing them, you won't get them to pay, unless you meet their guidelines. Medicare does allow family practitioners and other types of specialist to do diagnostic radiology services without any issue, as in they'll pay for it. I have a client who is a Internal Medicine/Pulmonologist here in NYC and he does tons of chest x-rays, etc bills without issue to MOST carriers, same with my Cardiologist, and my Endocrinologist (thyroid ultrasounds, etc). But, again each carrier is different. This is fairly common knowledge and flows across all modalities, and goes back to CareCore National Policies. if you have a client and or employer (doctor) who is billing outside of the scope of his specialty when it comes to diagnostic radiology services it's best to verify w/said carrier before services are rendered, because not all carriers allow it. Medicare does but not all carriers follow Medicare's guidelines and even Medicare tries to limit some of this, but you'll need to look at their LCD to determine how they do this. Tons of specialties CAN do diagnostic radiology services because it falls within the scope of their license, like say a OBGYN doing a pelvic ultrasound, or a PMR doctor doing injections w/fluoroscopic guidance, etc and so on.

Also, the  CPT codes you posted here are global codes, which means the doctor owns the equipment, supplies, has tech support, and interpreted the results (thus wouldn't be billed using any modifier b/c they're global codes), but if the carrier doesn't allow this particular doctor to do these services none of this will matter, which again it's best to check beforehand.

Again of this goes back to certain carriers adopting CareCore national policies on privileging. If you're interested in reading about all of this here is an old article: http://www.diagnosticimaging.com/articles/privileging-limits-access-imaging-cuts-insurers-costs
« Last Edit: May 29, 2013, 07:16:50 PM by Billergirlnyc »
Don't worry. Be happy.
~Dalia, CPC, CPC-H, RHIT.

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Re: RADIOLOGY ULTRASOUND
« Reply #4 on: May 29, 2013, 07:01:15 PM »

RichardP

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Re: RADIOLOGY ULTRASOUND
« Reply #5 on: May 29, 2013, 09:54:34 PM »
Also, the  CPT codes you posted here are global codes, which means the doctor owns ...

Just curious here.  Did you actually mean to say this:  Also, the  CPT codes you posted here are global codes, which should only be used when the doctor owns the equipment, supplies, has tech support, and interpreted the results (thus wouldn't be billed using any modifier b/c they're global codes) ...

Using global codes could mean nothing more than the doctor is not coding correctly.  I would hate to think that the doctor bought all of that equipment, supplies, and tech support without finding out whether he is authorized by the insurance carriers to use them.  I refer you to MTLOPEZ's comment THEY DENIED BECAUSE DOCTOR SPECIALTY, AND THE ALSO SAID HE IS NOT ALLOWED TO DOIT.  If this doctor is using global codes because he owns all of the equipment that is not appropriate to his specialty ...  :-\

Billergirlnyc

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Re: RADIOLOGY ULTRASOUND
« Reply #6 on: May 30, 2013, 01:51:50 AM »
Of course that's what I mean. If the OP says he's using those codes W/O any modifiers then I'm assuming he knows then he's billing for the global services, which includes both the technical and professional component.

But let me state this: -----> The OP was very specific with their question and to be very honest anyone knows these 2 carriers and bills for Radiology could've answered this question without the CPT codes you asked him to give. In fact I answered his original question and only touched on the codes because he posted them after you asked him, but I didn't need to know the CPT codes to answer his question and or direct him to links to get the answer he's seeking. The key components to his questions included that the doctor is a PCP, they're radiological ultrasounds, and that 2 major carriers in the northeast area Horizon BCBS of NJ (originally) and then he added Oxford on a follow-up response, are denying saying the doctor isn't authorized to do the services, and BOTH these carriers have adopted CareCore policies regarding privileging (for a while now) where diagnostic radiological imaging services are concerned. I know this because I code and bill Radiology for a large client of mines who has 4 free standing radiology facilities throughout the 5 boroughs in NYC. I knew why he was being denied at least by these 2 carriers.

Even if he used say CPT 76536 (global and has both a technical and professional component) he would only need to append the modifiers to show technical or professional if that's the case. So to say the code he's using is wrong is incorrect in my professional opinion. The code itself is CORRECT, the only thing that would be wrong is if he's suppose to use a modifier, which you broke down for him on which possible ones he could use. Again, I'm more than sure (due to the specifics) of the OP's questions he's not questioning WHICH CODE TO USE TO GET PAID, he's questioning WHY these aforementioned 2 carriers DENIED his doctor as not authorized, and I gave him links to what I believe is the answer. I work with both these carriers daily (as they're huge commercial payers in the northeast, in particular tri-state area (NY, NJ, CT) and I know all about their privileging policies for diagnostic radiology imaging services.

When Horizon BCBS of NJ says the doctor isn't AUTHORIZED they mean UNDER the policies they've adopted and implemented, thus why I suggested he verify with each carrier before rending diagnostic radiology services to a patient.

Lastly, there are PLENTY of doctors who ASSUME because Medicare allows and pays them then all carriers will, but in this instance where diagnostic radiological images are concern for Horizon BCBS of NJ and Oxford, it's just not the case, THUS my original response.
« Last Edit: May 30, 2013, 01:53:24 AM by Billergirlnyc »
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RichardP

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Re: RADIOLOGY ULTRASOUND
« Reply #7 on: May 30, 2013, 03:28:53 AM »
Dalia, it seems to be your opinion that the doctor was denied payment because he wasn't authorized by the specified carriers to do those services.  It also seems to be your opinion that the doctor might have been paid for the Professional Component if he had billed for that rather than billing for global services.

Those were the exact two points I made in my initial response.  I expanded on those two points and tied them to the issue of taxonomy codes in my second response, to provide some background information for others that might pass by this thread.  Yet I can't figure out if your last post above is agreeing with me or taking issue with my answer.

Billergirlnyc

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Re: RADIOLOGY ULTRASOUND
« Reply #8 on: May 30, 2013, 09:21:06 AM »
Richard, even if this doctor had billed w/the professional component he WOULDN'T be paid by either Horizon BCBS of NJ or Oxford (although he can confirm w/ Oxford b/c their link doesn't state it, but I know from billing them they don't allow professional or technical components if the ORDERING PHYSICIAN isn't privilege to do it - they want you to REFER out to a Radiology facility for those services the doctor isn't privileged for) because NEITHER allow a PCP to do radiological ultrasounds aka the CPT codes he posted. The links clearly state this. Furthermore Horizon BCBS of NJ link also states that the ONLY way the professional or technical component will be paid by them is if the POS is 21, 22, or 23 (basically inpatient hospital, outpatient hospital, or in the ER). So, no we DON'T agree on this point, because telling the OP to bill for the professional component will still render the services denied by these 2 carriers if these services were done in the office.

I'm pretty sure I never stated for him to bill w/either modifier, because again, I knew WHY he was being denied without even seeing the actual CPT codes as stated in my last comment. I also stated in my original comment:"Also, the  CPT codes you posted here are global codes, which means the doctor owns the equipment, supplies, has tech support, and interpreted the results (thus wouldn't be billed using any modifier b/c they're global codes),but if the carrier doesn't allow this particular doctor to do these services none of this will matter, which again it's best to check beforehand." . I think you may be confusing that I clarified on HOW the code can be billed, but I never stated he should bill either Horizon BCBSNJ or Oxford like this. I even stated he's not questioning the CPT codes or how to bill them, but why he was denied by these 2 carriers.

Direct quotes taken from the Horizon BCBNJ links:

"Horizon BCBSNJ does not consider a multi specialty practice with a radiologist on site as a freestanding radiology center. Any examination
that is performed outside of the ordering specialist’s privileging will not be reimbursed and will be the liability of the
specialty practice."

"All codes contained within this document represent global codes. Billing of Professional (PC) and Technical (TC) components are only acceptable in place of service (POS) 21, 22 or 23."


Now, Horizon does break down that certain PLANS are excluded from this, like a Medigap, etc., but I'm assuming the patient didn't have any of these plans, thus the denials the OP received, but I suggest he review the links to confirm, and IF the patient had one of the excluded plans, then appeal w/proof and copy of their policies stating the plan is excluded. That is my ONLY suggestion on this matter where these 2 carriers are concerned. Otherwise there is nothing more that will get either to be paid. But I hope my links are utilized by the OP so he knows the policies of these 2 carriers going forward and can inform/educate his doctor on them.
 
« Last Edit: May 30, 2013, 09:51:46 AM by Billergirlnyc »
Don't worry. Be happy.
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RichardP

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Re: RADIOLOGY ULTRASOUND
« Reply #9 on: May 30, 2013, 02:05:54 PM »
Thanks for the response.

So, no we DON'T agree on this point, because telling the OP to bill for the professional component will still render the services denied by these 2 carriers if these services were done in the office.

I think we will have to agree to disagree that we actually do agree with each other.  I was not telling the OP what to do.  I was raising issues that needed to be considered, and added this caveat:

Note that if your doctor is taking the picture, reading the picture, and implementing a procedure(s) based on the results of the read, you need to bill for both the TC and PC components.  But that doesn't mean the insurance carrier will pay for either component charge.

It still seems to me like you and I are on the same side of the larger issue that I was addressing.  That is, taxonomy matters when talking about what procedures the insurance carriers will pay the doctor for.  The only difference in our comments is that I wasn't certain what the insurance carrier would pay for (we don't deal much with Horizen BCBS) and so was not being specific.  You were certain, because you knew, and so gave a more specific answer.  That is, I was not giving an answer specific to Horizon, but you were.  I was only giving a general response regarding the issue of taxonomy.  Again, thanks for the feedback.

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Re: RADIOLOGY ULTRASOUND
« Reply #9 on: May 30, 2013, 02:05:54 PM »

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Re: RADIOLOGY ULTRASOUND
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