Billing > Billing
RADIOLOGY ULTRASOUND
mtlopez:
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:
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:
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:
--- Quote from: mtlopez on May 25, 2013, 12:30:55 PM ---WE ARE NOT USING MODIFIERS
--- End quote ---
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.
--- Quote from: mtlopez on May 25, 2013, 12:30:55 PM ---THEY DENIED BECAUSE DOCTOR SPECIALTY, AND THE ALSO SAID HE IS NOT ALLOWED TO DOIT.
--- End quote ---
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:
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
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