ED Coding and Reimbursement Alert

Most providers list dozens of diagnoses for chest exams

When your ED physician performs multiple exams, you must prove medical necessity with solid ICD-9 coding and choose a modifier to indicate physician involvement, or risk claim rejection.

We-ll make getting paid easy with this advice on coding single and multiple chest x-ray claims in the ED.

Check LCDs for Covered X-Ray Diagnoses

Patients who might require ED chest x-rays run the gamut, from accident victims to potential heart attack sufferers, says Stacy Gregory, RCC, CPC, from Tacoma, Wash.-based Gregory Medical Consulting Services. In addition to trauma patients, she lists the following conditions as possible precursors to a chest x-ray:

- chest signs and symptoms--chest pain, cough, congestion, difficulty breathing, or shortness of breath
- abnormal chest sounds (such as wheezing, rales, or crackles)
- fever/or cold and flu symptoms
- known or suspected myocardial infarction or cardiac arrest
- abdominal pain.

Example: A patient with chest pain and labored breathing reports to the ED. The ED physician performs a single-view frontal chest x-ray. The results show the patient did not have a cardiac episode. On the claim, report the following:

- 71010 (Radiologic examination, chest; single view,  frontal) for the x-ray
- modifier 26 (Professional component) linked to 71010 to show that you are only billing for the interpretation of the x-ray
- 786.50 (Chest pain, unspecified) linked to 71010 to represent the patient's chest pain
- 786.09 (Dyspnea and respiratory abnormalities; other) linked to 71010 to represent the patient's breathing trouble.

Acceptable diagnoses: Your carrier has the final say on what codes prove medical necessity for chest x-rays, Gregory says. For example, Noridian Medicare in Washington state lists its acceptable ICD-9 codes at www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=23709&lcd_version=2&show=all.

Best bet: If you don't know what diagnoses your Medicare carrier covers for a chest x-ray, check out the local coverage determination (LCD). (For private payers, consult individual policies.) -There are more than 100 ICD-9 codes that support chest x-rays. It is one of the best-covered exams,- says Lori Hendrix, CPC,
CPC-H, coding consultant with Coding Strategies Inc. in Powder Springs, Ga.
                                                           
Use Modifiers on Multiple Chest X-Rays

Sometimes, the ED physician will perform more than one chest x-ray on the same patient on the same date. This might be necessary in several situations, Gregory says. A second x-ray might be needed if:

- the physician requests additional views
- x-rays are performed before and after performing a procedure such as intubation or placement of a chest tube.

Example: A patient presents to the ED with chest trauma after crashing his car into a boulder that fell onto the road. The physician performs an initial single-view chest x-ray and identifies a traumatic pneumothorax.

The physician immediately places a chest tube to allow the lungs to re-expand. After the insertion, the ED physician takes a second single-view chest x-ray. The same ED physician performs and interprets both x-rays.

For the x-ray portion of this encounter, Gregory says, report the following:

- 71010-26 (Radiologic examination, chest, single view, frontal) for the first x-ray
- 860.0 (Pneumothorax without mention of open wound into thorax) linked to 71010 to represent the pneumothorax
- E815.0 (Other motor vehicle traffic accident involving collision on the highway; driver of motor vehicle other than motorcycle) linked to 71010 to represent the accident
- 71010-26 for the second x-ray, with 860.0 and E815.0 appended to prove medical necessity
- modifier 76 (Repeat procedure by same physician) linked to the second 71010 code to show that the same physician performed and interpreted both x-rays.

Remember: Don't just slap modifier 76 on every multiple x-ray claim; you-ll need to choose your modifier carefully based on the situation.

Consider the above encounter: Suppose physician A performs and interprets the first x-ray, but physician B interprets the second x-ray. Instead of modifier 76, you-d attach modifier 77 (Repeat procedure by another physician) to the second x-ray code to explain the second physician's involvement, Hendrix says.

And if the physician performs two different types of x-rays (one single-view and then one two-view, for example), report the second code appended with modifier 59 (Distinct procedural service), regardless of who interpreted the exams, Gregory says.