Exam without interpretation

goodjegoodje
in COMPLIANCE

I'm looking for official guidance, but falling short. Does anyone have a source that speaks to billing the technical/facility charge of an exam, if the interpretation is not expected to be completed? I have the date of service policy, allowing the family to bill before it's complete, but I'm looking for something a little more straightforward. Would an exam without interpretation still meet medical necessity?

Comments

  • RHirschRHirsch

    It's a fascinating question. I have never seen guidance on billing if an interpretation is never going to be done and have to think that it's not billable at all since that sounds like an unnecessary study. (But when would this ever happen???)

    But if there will be a delay in interpretation, if you are only billing the technical fee and using -TC then I see no reason to hold the claim for an interpretation which the provider will bill with -PC. Now if you are billing the global fee, you should hold it for the interpretation to be done.

    When billing global service, the provider can submit the date of service of the professional component with a date of service as the date of the review and interpretation or the date the technical component was performed. If the provider did not perform a global service and instead performed only one component, the date of service for the technical component would the date the patient received the service and the date of service for the professional component would be the date the review and interpretation is completed. https://www.cgsmedicare.com/partb/pubs/news/2025/02/cope172553.html

  • goodjegoodje

    Thank you, Dr. Hirsch, we also thought it wouldn't be considered necessary if not interpreted. It's a unique situation, and there was intent to interpret when the study was performed and ordered, but provider circumstance changed.

    We were given guidance after I asked here that it's not allowed based on the LCD language (First Coast - L33405) "The raw data from all sleep tests must be reviewed and the tests must be interpreted." That line is under the heading "Physician" though, which makes it a potential point of argument that I'd prefer to avoid.

  • RHirschRHirsch

    Now the next question is (unrelated to billing)- do you leave it uninterpreted? What if it shows something significant and potentially life-threatening? Since it is a sleep study, I would assume the technician would have seen anything bad and spoke up, but maybe not. So that's worth a discussion with your risk management team.

Sign In to comment.