ED Coding and Reimbursement Alert

Follow these tips to 'x' out denials

Your emergency department (ED) performs chest x-rays regularly, but you still can't always answer those nagging coding questions. Let our experts do it for you with these tried-and-true guidelines.

Add Modifiers for Multiple Chest X-Rays

Question: Can we report 71010 (Radiologic examination, chest; single view, frontal) more than once on the same date? For instance, we might perform two or three single-view chest x-rays if a patient has a pneumothorax and receives a chest tube.

Answer: One of the most important things to remember when billing multiple chest x-rays on the same day is to make sure your diagnosis code supports medical necessity -- and pneumothorax (512.x) clearly falls into that category. "Patients requiring intubation and then repositioning of the endotracheal tube will also frequently receive multiple chest x-rays," says Michael Granovsky, MD, CPC, FACEP, vice president of coding at MSRI in Stoneham, Mass. You should look for a diagnosis of respiratory failure or indications that the patient was intubated to tip you off to multiple x-rays, Granovsky says. In these situations, the ED physician must monitor the status of the patient's lungs so he can react immediately if anything should change.

The modifier is key: You should append modifier -76 (Repeat procedure by same physician) to the subsequent x-rays if the same physician interprets them. If a different physician interprets the follow-up x-ray, you should add modifier -77 (Repeat procedure by another physician).

Suppose a newborn has respiratory distress syndrome (769) and the physician orders two chest x-rays, six hours apart, to assess how well the infant's lungs are functioning. If your ED physician reads the first x-ray, you should report 71010. If a radiologist reads the subsequent x-ray, he should report 71010-77.

Apply -76 and -77 to Matching CPT Codes

Don't miss: If the ED physician performs a single-view chest x-ray and a radiologist performs a two-view chest x-ray, you should not append these modifiers to either code. Instead, you should report 71010 for the first x-ray and 71020 (Radiologic examination, chest, two views, frontal and lateral) for the second when performed on the same date of service.

However, if two different physicians report the same x-ray code on the same patient, you may need to append modifier -77 to inform payers that it was a repeat procedure by another physician (rather than two physicians billing for the same service). Be prepared to demonstrate medical necessity for both the second x-ray and interpretation.

If the same physician performed two chest x-rays, one before treatment and one after, you'd append modifier -76 in order to follow the same requirement for medical-necessity documentation.

Individual payers may set their own limits that determine how frequently you can report follow-up chest x-rays for pneumothorax, and some payers may try to bundle the subsequent x-rays. If this happens, resubmit the claim with copies of each of the chest x-ray reports. And you should always document the time of day in which you perform each x-ray.

Rib X-Ray? Choose 71100 Over 71020

Question: We typically report 71020 for two-view rib x-rays. An auditor we hired said that this is incorrect. What are we doing wrong?

Answer: Reporting 71020 is incorrect coding in this case because CPT includes several, more specific rib x-ray codes. You should report 71100 (Radiologic examination, ribs, unilateral; two views) for a two-view rib x-ray. Although the ribs and chest encompass the same portion of the body, they are distinct procedures.

You'll often report a chest x-ray code when you assess soft tissue structures within the rib cage for conditions such as bacterial pneumonia (482.x) or a neoplasm (162.3, Malignant neoplasm of trachea, bronchus and lung; upper lobe, bronchus or lung).

You'll report the rib x-ray codes (71100-71111) if you study the bony structures for conditions such as trauma (for instance, a fracture sustained in a car accident, 807.0x, Fracture of ribs, closed) or intractable rib pain.

Tip #1: The National Correct Coding Initiative bundles 71010 into 71100, and you can report these codes separately only if you append a modifier and explain why you assigned both codes. For instance, you might perform a rib x-ray during an ED encounter if a patient has a rib fracture that caused a pneumothorax. Several hours later, you might perform a single-view chest x-ray to determine the status of the pneumothorax. In this instance, you should report codes 71100 and 71010-59 (Distinct procedural service).

Tip #2: Remember that for the ED physician to bill for the interpretation, the x-ray report must be a complete, written report equal to what a specialist in the field would give, says Robert La Fleur, MD, FACEP, president of Medical Management Specialists. The report does not have to be a separate document - it can be part of the ED dictation, La Fleur says.