Specialty rules are applied to the practice's payers, documentation, and schedule during the engagement.
Where the billing gets difficult
Global codes for a hospital read
Reading a hospital study does not include the hospital's technical component. Global billing overstates the service.
Orders with a symptom and no covered indication
The radiologist did not choose the indication. A vague order produces a denial the read cannot fix.
Comparison studies and incomplete reports
A report that is not signed, or a preliminary read billed as final, will not hold.
Coding considerations
Modifier 26 and TC
Professional and technical components are split when the work is split. Global codes are reserved for combined work.
Modality and views
The code follows the examination performed, including contrast and the number of views when the definition uses them.
Screening versus diagnostic
Mammography and similar services change code family when the study is screening rather than diagnostic. The order decides.
Documentation the claim needs
- A signed final report
- Technique sufficient to choose the code
- Indication forwarded from the order
- Site and ownership that justify global versus professional-only billing
Reimbursement complexity
Radiology groups lose revenue by billing the wrong component and by reading studies whose authorization or indication was never cleared. The professional fee is smaller than the technical fee, so a global code that is later recouped hurts. Denials should be sorted into indication problems, which belong with the ordering clinician's process, and component problems, which belong with the radiology group's setup. This service does not bill a hospital's technical component.
Proposed approach
01
Set the component by site
Each location is flagged as professional-only or global before the first claim.
02
Release only signed finals
Preliminary reads are not billed as final reports.
03
Feed indication denials back to ordering
Repeating indication problems are reported as an ordering issue, not only an appeal.
Workflow checks
- Site component map
- Signed-report release
- Code from technique
- Auth and indication exception list
Questions
Do you bill the imaging center's technical fees if we only read?
No. Professional-component billing is the correct scope for a read-only relationship.
Can you add a diagnosis so a study will pass an edit?
No. The indication is the ordering clinician's. A query can ask for a clearer order. It cannot invent a finding or a history.