Use caution when billing for remote radiology reading

Sandy Coffta.

The ability to have radiologists work at locations remote from the patient exam site can be a great boon to efficiency and turnaround time. This practice has become more prevalent with the advent of faster network connections, and it has increased significantly since the COVID-19 pandemic when more people began working offsite.

Compliant billing for remote reading services is not always as straightforward as normal onsite billing, and radiology practices must be aware of the requirements of each payer, most especially those of Medicare and other government programs.

Medicare regulations

Medicare first issued its Place of Service (POS) reporting regulations with an effective date of April 1, 2013. Those rules have been in effect for well over ten years, and radiology practices most likely are already familiar with their application. Here’s a quick summary:

Service Facility Location (Payment Locality)

• The use of Global Billing depends on the location of the professional and technical component services as well as the relationship between the parties.
• When professional and technical components are billed separately, the Service Facility Location should reflect where the service was actually provided. In the case of a radiologist, this would be where the interpretation was completed.
• The fee schedule to be used for payment will depend on the actual location of the services, based on zip code. The fee schedule for the professional component may be different from that of the technical component.

Place of Service (POS) Coding

• This generally follows the location where the patient’s exam took place, even if the interpretation was performed remotely by teleradiology.

Global vs. Split Billing

Global billing is used when the interpreting physician is a part of the same billing entity as the imaging center (either as an employee or under direct contract) and when the physician’s location while providing the interpretation is in the same payment locality. In this case, the address to be used is that of the imaging center alone, regardless of the physician’s location when providing the interpretation. However, if the interpretation takes place in a different payment locality, split PC/TC billing (attaching modifier -26 for the PC) must be used with the location of each component reported separately. An unusual or infrequent location, such as a hotel or other vacation location, is not to be entered on claim forms; instead, the address of the physician’s most common practice location is to be used.

When the billing entity providing the Professional Component (PC) is different from the one providing the Technical Component (TC), e.g., in the case of hospital patients, the PC is billed separately using modifier -26. The location (address and zip code) where the interpreting physician performed the professional component services is reported.

See Table 1, below, for assistance with applying these rules.

Location of Physician (PC) services

The physical address, including the zip code, where the radiologist provided the interpretation is to be entered on claims in Box 32 of CMS-1500. The address entered in Box 32 will determine the fee schedule to be used based on the payment locality of the zip code. Practices located near the border of payment localities should be aware of the payment levels in each in order to avoid unintended lower payments or to take advantage of higher payment levels by using teleradiology strategically.

Many radiologists interpret images from their homes, and the home address will have to be reported whenever separate PC billing is required if the home is in a different payment locality than the imaging site. An unusual or infrequent location, such as a hotel or other vacation location, is not to be entered on claim forms; instead, the address of the physician’s most common practice location is to be used.

Place of Service code assignment

The Place of Service (POS) code should reflect the place where the patient ‘face-to-face’ interaction occurred, regardless of where the reading was done. PC claims for hospital outpatient cases read by the radiologist from an imaging center would carry the POS code 22 for Outpatient Hospital because that is where the patient was seen, not code 11 for the radiologist’s location.

An exception to this rule is for inpatients of a hospital or other facility that might be transported to an imaging center for an exam. In this case, the patient exam would be coded 21 (Inpatient Hospital), rather than code 11, for the office where the exam actually took place. The same would apply for a registered hospital outpatient if services were provided elsewhere.

The POS code is to be entered in Box 24 of claim forms. The most common codes for radiology services are as follows:

Physician Office	POS code 11
Outpatient Hospital	POS code 22
Inpatient Hospital	POS code 21
Emergency Department	POS code 23
Ambulatory Surgery Center	POS code 24

The Medicare rules are contained in CMS Change Order #7631 and clarified in a Frequently Asked Questions document.

Common scenarios

What has changed in recent years is the increased mobility of radiologists and the inadvertent failure to properly report their reading location. The radiologists may not realize they need to tell their billing staff about their reading location when it differs from their usual workplace.

The issue with billing arises when the radiologist reads from a location in a different Medicare payment locality from their regular practice locality. Often the payment locality covers an entire state, but in some states, there is more than one locality. An example is New Jersey, where a practice in the northern part of the state might have a radiologist who lives in the southern part of the state and reads from their home. This can easily occur by traveling one town away from the practice’s main location!

A radiologist who does final reading offsite from the hospital or imaging center needs to understand these guidelines:

• If you are reading in a state other than the one in which the imaging facility is located, you must have a medical license in the state where you are reading.
• The practice must submit claims for Medicare patients in the payment locality where the final reading takes place. If you are reading from an off-premises site, be sure to let your billing team know so they can ascertain that the practice is registered with Medicare in your locality.
• There are a few caveats:
• If you do preliminary reading offsite, and complete the final reading from the hospital or imaging center where the patient exam took place, these rules do not apply.
• If you are out of state temporarily (e.g., vacation) then the Medicare rules do not apply. You should still investigate the medical-legal aspect of state licensure in that circumstance.

Here are some examples using a hypothetical practice located in Massachusetts:

• You work and live in Massachusetts; you may read and create final reports from home.
• You work in Massachusetts but live in New Hampshire; you may create final reports from home if you have a New Hampshire license and notify the billing team of the reading address. You may create preliminary reports from home if the final is signed off from the hospital.
• You live and work in California reading exams done in Massachusetts; you must have a license in both California and Massachusetts and notify the billing team of your reading address.
• You work and live in Massachusetts but are on vacation in Cape Cod, MA; you may create final reports. There is no need to notify billing.
• You work and live in Massachusetts but are on vacation in Florida; you may create final reports but check on the legal aspect of licensure. There is no need to notify billing.

Some practice systems might automatically capture reading location, but in the end, it is the physician’s responsibility to notify the practice about their work location. Making them aware of these guidelines, especially as they relate to medical licensure, will help ensure that the practice is in full compliance.

Conclusion

The easy availability of remote reading and the postpandemic shift to offsite work has renewed the need for practices to be aware of the Medicare rules for reporting the place of service in order to be compliant. After-hours reading by radiologists in distant locations will produce a reimbursement rate different than the one in effect at the imaging center or hospital. In some cases, this can be used strategically to move interpretations to a location with higher reimbursement rates. The first step is to develop a system that allows the billing team to know the location of the reading services, so they can be sure to apply the rules properly.

Patient Face-to-Face Location	PC Entity vs. TC Entity	Radiologist Location	Type of Billing	Address (Zip Code) for PC
Hospital IP, OP, ER	Different	Hospital	Split PC/TC	Hospital
Hospital IP, OP, ER	Different	Offsite	Split PC/TC	Radiologist’s Office
Imaging Center	Different	Imaging Center	Split PC/TC	Imaging Center
Imaging Center	Different	Offsite	Split PC/TC	Radiologist’s Office
Imaging Center	Same	Imaging Center	Global	Imaging Center
Imaging Center	Same	Office in same payment locality	Global	Imaging Center
Imaging Center	Same	Office in different payment locality	Split PC/TC	Radiologist’s Office

• “Office” includes any location where the radiologist regularly works, which could include his or her home.
• “Imaging Center” includes a physician office or ASC setting.
• A vacation hotel or other temporary location should not be reported; the address of the radiologist’s regular work location should be reported in Box 32.

Sandy Coffta is the vice president of client services at Healthcare Administrative Partners.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.