X-ray Interpretation and Report Performed in the Emergency Room

This policy applies to HMSA’s PPO, HMO Plans, and HMSA QUEST Plans.

Effective August 1, 2011, HMSA adopted Medicare’s policyⁱ regarding X-ray interpretations for Emergency Room (ER) patients. HMSA now reimburses ER physicians for interpretations of X-rays performed in the ER. This interpretation and report must directly contribute to the diagnosis and treatment of the patient.

HMSA will cover only one interpretation and report per member, per service, where the place of service is the ER. The interpretation and written report should be included in the hospital’s medical record and should address the following:

• The findings
• Relevant clinical issues
• Comparative data (when available)

A routine notation in the ER notes indicating that the “X-ray is normal” does not meet HMSA’s criteria for separate payment for X-ray interpretation and report. Reimbursement for this level of reading is included in the E&M service.

There may be instances where ER physicians and radiologists need to confer and reach an agreement about who should bill for a radiology interpretation for an ER patient. However, in the event both specialties provide interpretation services to the same patient and duplicate claims are submitted, HMSA will make payment on the first claim it receives. If there is a request for reconsideration of payment denial on the second claim, HMSA will see that payment is directed to the provider whose interpretation is used in the diagnosis and treatment of the patient. This could result in recovery of the payment made on the first claim.

HMSA will also recognize modifier 77 (repeat procedure by another physician) for separate payment when billed by the radiologist. This indicates that in addition to the findings of the ER physician, different findings were noted and documented by the radiologist.

ⁱ(Medicare Claims Processing Manual Chapter 13 - Radiology Services and other Diagnostic Procedures, Section 100 Interpretation of diagnostic tests, Rev. 2096, 11-19-10)[PDF]

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