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Dec 5th, 2018 - Denise J   

Ordering and obtaining precert/prior auth for Motility Studies @ the hospital

Quick question. We are having trouble with getting the correct codes for our Motility studies. We are now running in to the problem of having our Motility studies needing to be precerted or needing prior auth. We only charge for the interpretation of the study, so the code we use is 91010-26. The hospital is getting precert for the cpt code 78258 which is under Nuclear Radiology: Digestive system, along with cpt code 91299 which is unlisted diagnostic gastroenterology procedure; and is ultimately being denied. The hospital representative told our nurse that we should be ordering and precerting for the Radiological code as well as the interpretation code. How is everyone handling this, and are you getting auth for Radiological code as well as interpretation codes??

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Dec 20th, 2018 - ChrisW   122  1 

re: Ordering and obtaining precert/prior auth for Motility Studies @ the hospital

If you are billing for the hospital and 91010 includes the STUDY (i.e., procedure) as well as the interpretation and report, who gets paid for the study if you only bill for the 26?

If I am understanding correctly...

In looking at the Medicare Physician Fee Schedule (MPFS) Indicator, 91010 is designated as a # 1 - Diagnostic Tests for Radiology Services - (Identifies codes that describe diagnostic tests). Examples are pulmonary function tests or therapeutic radiology procedures, e.g., radiation therapy. These codes have both a professional and technical component. While modifiers 26 and TC can be used with this code the hospital should be getting approval and billing the professional component as well as the technical component. I would suggest contacting the Payer if there is more to it than what I have addressed hope this helps.

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