Respiratory Physicians

12 January 25

We have a scenario where Medicare reject claims submitted by the physician for an item 38417 because it states fluoroscopy can only be claimed by one provider once for that occasion of service. The physician performs the bronchial biopsy and a radiologist performs the fluoroscopic imaging to guide the physician when taking the biopsy. In this case the doctor physician claimed a 38417. The radiologist claimed a category 5 diagnostic item group 13 MBS item and the radiologist claim was submitted prior to the physician lodging their claim. As stated by the physician, “38417 is the most correct item number for the procedure. The item description does say “with or without associated fluoroscopic imaging”. I performed the procedure described as MBS 38417 for an ultrasound biopsy and the radiologist performed and billed the fluoroscopy. “It does not seem right that the physician cannot claim the 38417 when by description the procedure fits exactly with this item.” When two providers need to partake in the provision of a service due to the particular areas of specialty (i.e. medical procedure v diagnostic imaging), what is the best approach when dealing with Medicare and the claim?

5 October 24

This questioner said that every time they called Medicare about this, they received different advice and were concerned they may be billing incorrectly. The setting was outpatient sleep studies which are bulk billed by the respiratory and sleep physicians using item 12250. The company (described as an external provider) supplies the patients with the sleep study devices and charges them a hire fee for the equipment. Is this allowed?

4 October 24

The specialist had received a referral from another respiratory physician to perform a bronchoscopy on a patient. The specialist called the patient to discuss the procedure, make them aware of the risks and what could be done as part of the procedure i.e. a biopsy. The patient was given the opportunity to ask any questions they had about the procedure and the costs were explained. The phone consultation was documented in the patient’s record. No previous billings for the patient with the referral have been made yet

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