Radiology, Preliminary and Double Reads

Reimbursement Policy:
Radiology, Preliminary and Double Reads

Effective Date:
January 1, 2013

Purpose:
This policy establishes consistent reimbursement methodology guidelines for the processing of claims for Radiology Services billed with Modifier 26 in conjunction to an Emergency Room (ER) Place of Service (POS).

Products:
All products are included except for products where Horizon is secondary to Medicare (i.e. Medigap). All Insured and ASO accounts are included.

Definitions:
Preliminary Reads (aka Wet Reads): is a concise diagnosis of the medical condition of a patient, with recommendations for additional procedures, as diagnostically applicable. It is an incomplete diagnosis as it focuses on a single aspect of the patient’s condition. Preliminary reports are primarily used for emergency department coverage and as such, thirty minutes or less is the industry standard of care.

Professional Component (modifier 26) - is the permanent interpretation of a diagnostic procedure. It should contain all of the elements and clinical detail of a well-written report in accordance with the standards established by the radiology practice and the recipient hospital or medical center.

Documentation of any discrepancy between the preliminary and final review must also be included. The final report is entered into the patient’s permanent medical record, and is the document used to invoice payers for professional services rendered.

*Applicable to all diagnostic imaging including Cardiology.

Evaluation and Management (E&M) codes: A preliminary read (a.k.a. Wet Read) is considered part of the initial E&M code. There can be only one official interpretation of the films or procedure by a radiologist. The film review is considered part of the ER evaluation and management reimbursement. If the service is performed in the ER and a preliminary read is performed by the ER physician/group, then the physician/group cannot bill unless an official report (interpretation and written report) has been completed. Therefore, reimbursement would only be issued to the radiologist who performed and completed the interpretation and report.

Policy:
A Preliminary Read (aka: Wet Read) is considered part of the initial E&M and also included in the billing for the diagnostic procedure. There can be only one official interpretation of the films or procedure by a radiologist and is not separately payable to another physician.

If the service is performed in the Emergency Room and a Preliminary Read performed by the emergency room physician, the emergency room physician (group) cannot separately bill. The film review is considered part of the emergency room evaluation and management payment. Therefore, reimbursement would only be paid to the radiologist who performed and completed the interpretation and report.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group benefit

• Provider contract

• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity

• Mandated or legislative required criteria will always supersede

Procedure:
If procedure code 70101 is performed in the emergency room and a preliminary read is done by the ER physician or ER group and then a radiologist reviews and interprets the exam (creating an official written report) the radiologist may bill 70101-26 and get paid. The ER physician billing E&M code 99283 and a radiology code of 70101-26, the system should deny the radiology code as inclusive to emergency room visit.

Message:
This procedure is not eligible for separate reimbursement.
There is no member liability for such a denied service if that service is performed by a participating provider.

References:

• AMA CPT Code Resource

• CMS Medicare Claims Processing Manual

• Chapter 13 - Radiology Services and Other Diagnostic Procedures (20.1)

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