Inpatient Facility Coding & Compliance Alert

Question: In a patient who incurred a leg injury following a car accident, the surgeon ordered an x-ray of the lower limbs. X-rays were requested for both the affected as well as the normal lower limb for comparison. The insurer denied the x-ray claim for the unaffected leg and only paid us for a unilateral x-ray. What could be the reason for this denial? Please advise.

Arizona Subscriber

Answer: Comparison views for legs are usually obtained and reimbursed in the case of children because providers may sometimes order comparison views to rule out growth-plate injuries.

However, in adult patients, you cannot always submit claims for comparison views, as there may be no medical necessity. The insurers consider x-rays of the non-injured side as a screening x-ray.

Keep documentation: If your physician obtains comparison images of the opposite leg to determine leg length (in event of a fracture), the payer may consider this medically necessary. In that case, your provider needs to document clearly why the comparison view is needed. You should then submit the claims with the LT (Left side) and RT (Right side) modifiers, and include documentation in which the physician describes the medical necessity for the unaffected side. 

How to code? You can submit the x-ray code V72.5 (Radiological examination, not elsewhere classified). When ICD-10 is implemented and your diagnosis system changes, you will report Z01.89 (Encounter for other specified special examinations).