General Teaching Documentation and Coding Guidelines for Radiological Services

Title: General Teaching Documentation and Coding Guidelines for Radiological Services
Standard #:

DC-319

Issued: 12/01/1997 Reviewed/Revision Date: 08/21/2000, 10/06/2009, 07/01/2012, 12/09/2014

DEFINITIONS

Teaching Physician – A physician (other than another resident) who involves residents in the care of his or her patients

Resident – An individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.  The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the Fiscal Intermediary.  Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of “resident”.  Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents

STANDARD

Diagnostic services

For diagnostic services, the teaching physician must personally review the images and interpret the test results in order to bill a professional fee. The medical record must be clear that the teaching physician actually reviewed the images.

For diagnostic procedures where the physician would not be expected to be present; such as, an x-ray, the teaching physician could bill for an interpretation by either viewing the film with the resident or by performing an independent interpretation.

Documentation of the x-ray findings must be provided in a separate, written report to be considered for payment.  The services of the physician who merely reads the x-ray but never documents a written report of the interpretation, would be considered an integral part of the Evaluation and Management services provided to a patient and therefore, not separately billable.

If the signature on the interpretation is that of the teaching physician, Medicare assumes that he/she is indicating they personally performed the interpretation.  If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the resident’s interpretation and agrees. If the teaching physician disagrees with any of the resident’s interpretation, the appropriate edits should be made to the findings.

Medicare will not pay for an interpretation where the teaching physician only co-signs the resident’s documentation.

Supervision and Interpretation services

Radiologic supervision and interpretation (S&I) codes are used to describe the personal supervision of the performance of the radiologic portion of a procedure by one or more physicians and the interpretation of the findings.  In order to bill for the supervision aspect of the procedure, the physician must be present for the entire radiological service.  The interpretation of the procedure may be performed at the same time or later by the same or another physician.  In situations in which a cardiologist, for example, bills for the supervision (the ‘S’) of the S&I code, and a radiologist bills for the interpretation (the ‘I’) of the code, both physicians should use a -52 modifier indicating a reduced service of only one of supervision or interpretation.

Signatures

Electronic signatures on dictated radiology reports are acceptable as long as electronic default statements are not used in the place of patient specific documentation. Security systems must ensure that the electronic signature can only be applied by the physician.

REGULATORY REFERENCES

Medicare Claims Processing (PUB. 100-04)
Chapter 12 – Physicians/Nonphysician Practitioners
100 – Teaching Physician Services (Updated through Rev. 2303 **Rescinds and Replaces Transmittal #2247, dated 06/24/11**; Effective: 06/01/11; Issued: 09/14/11)

Medicare Claims Processing (PUB. 100-04)
Chapter 13 – Radiology Services and Other Diagnostic Procedures
80 – Supervision and Interpretation (S&I) Codes and Interventional Radiology (Rev. 1, 10-01-03)

QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Help & Reporting Line at (213) 740-2500 or (800) 348-7454.