Orthopedic Coding Alert

 You'll hit your claims on the mark every time with these expert tips

If you can't get a handle on coding x-ray services, you're not alone. But as long as you document the x-ray type and quantity, you'll be on your way to x-ray expertise.
 
According to CMS data, x-ray codes make up nearly half of orthopedists' 20 most frequently performed procedures, but x-rays can still confound even the most seasoned orthopedic coder. Secure reimbursement for these procedures with the following expert answers to your most pressing x-ray questions.

Standing Knee View Won't Always Warrant 73565

Question 1: Your practice performs a two-view left knee x-ray while the patient lies flat, and another left knee x-ray while the patient stands up. Can you report both 73560 and 73565?

Answer: No. Because 73565 (Radiologic examination, knee; both knees, standing, anteroposterior) describes "both knees," you cannot report this code with 73560 (Radiologic examination, knee; one or two views) if you only examine one knee.
 
Instead, you should add up the total number of views that you took, says Anne Crandall, LPN, office manager at Spine and Sports PC in Memphis, Tenn. Therefore, if you perform two views of the left knee while the patient lies in the supine position and one standing view of the left knee, you should report 73562 (Radiologic examination, knee; three views).
 
You should report 73565 only if you perform anteroposterior (AP) upright views of both knees.

Document X-Ray View Types, Not Just Quantity

Question 2: The orthopedist requests a complete cervical spine x-ray series. Your office's x-ray technologist shoots and documents five spine views, so the coder reports 72052. Is this the correct code?

Answer: Determining the correct code is impossible, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management, a medical reimbursement consulting firm in New Jersey. Your x-ray tech may have shot five views, but because the tech didn't document the types of views, you can't tell whether she performed a complete series or whether she simply shot five anteroposterior AP views. You probably assume that the tech would never perform five AP views, but you'll find it impossible to prove otherwise without the appropriate documentation.
 
Although x-ray technologists should always document the number and types of radiologic views they take, the types of views - not just the number - will help you determine your code.
 
If your practitioner dictates only five cervical spine views, the highest code you can assign is 72050 (Radiologic examination, spine, cervical; minimum of four views). To report a complete series (72052, Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies), you must shoot bilateral oblique views, a flexion-extension lateral view, and articular pillar (facet) views. If the x-ray tech doesn't document these views, your code automatically defaults
to 72050.
 
Reality: If you perform a complete cervical spine series, but you only document a "five-view" study, you forfeit about $11.50 - the difference in Medicare's reimbursement between 72050 and 72052 (based on the 2004 Physician Fee Schedule, unadjusted for geographic differences).

Rib X-Ray Only? Choose 71100 Instead of 71020

Question 3: Your practice typically reports 71020 for two-view rib x-rays, but a radiology consultant told you that this was incorrect. Who is right?

Answer: The consultant is correct. You should not report 71020 (Radiologic examination, chest, two views, frontal and lateral) 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.
 
Non-orthopedic coders (such as pulmonologists) often report chest x-ray codes when they assess soft-tissue structures within the rib cage for conditions such as bacterial pneumonia (482.x).
 
Orthopedic coders, however, usually report the rib x-ray codes (71100-71111) if they study the bony structures for conditions such as trauma (for instance, a fracture sustained in a car accident [807.0x, Fracture of rib(s), closed]) or intractable rib pain.

Expect Denials With Comparison X-Rays

Question 4: A 23-year-old patient presents to your practice with a left knee injury that he sustained while bicycling. The orthopedist orders comparison views of the left and right knees. The insurer denies the claim for the right knee x-ray. Why?

Answer: Although your payer may reimburse comparison views of children's knees, you can't usually collect for comparison views that you take of adult patients.
 
"Doctors sometimes order comparison views of children because they suspect growth-plate injuries, and comparing the left side to the right can confirm this type of injury," Crandall says. "But in an adult patient, the insurer sometimes considers the non-injured side a screening x-ray because you lack the appropriate diagnosis to justify medical necessity on the healthy knee."
 
The National Coverage Determination for Cahaba Government Benefit Administrators (a Part B carrier in Alabama), for instance, states, "Bilateral radiographs, for 'comparison' of a symptomatic knee with a patient's asymptomatic knee, are not usually medically necessary in the adult patient."
 
If your physician believes that he requires the comparison view for medically necessary reasons, you should submit the claims with the -LT (Left side) and -RT (Right side) modifiers, and include a letter in which the physician describes medical necessity for the right knee x-ray. He should link the x-rays to V72.5 (Radiological examination, not elsewhere classified).

Use Modifiers for Repeat Surgical X-rays

Question 5: Your orthopedist orders prereduction x-rays and interprets the films. He surgically reduces the fracture and orders postreduction x-rays as well. He dictates separate notes for each interpretation. Can you report both pre- and postreduction x-rays?

Answer: If you order the films to document the "before and after" condition of the patient's fracture, your insurer will probably bundle the films into the reduction, Crandall says. 
 
If, however, the orthopedist orders the prereduction x-rays to diagnose the fracture and subsequently interprets postreduction films to confirm alignment, your insurer should reimburse both interpretations, as long as the physician documents the services appropriately.
 
Modifiers make the difference: Suppose you interpret a medically necessary two-view study of the patient's ankle before surgery to diagnose the fracture site and another two-view study after surgery to ensure that you aligned the fracture correctly. You should report 73600-26 (Radiologic examination, ankle; two views; Professional component) followed by 73600-26-76 (Repeat procedure by same physician).
 
Modifier -26 tells the insurer that you performed only the professional portion of the x-ray (the hospital probably performed the technical component).
 
Modifier -76 tells the insurer that you performed the same procedure twice. But if the physician performed a two-view ankle x-ray before the surgery and a three-view complete ankle x-ray after surgery, you should report 73600-26 for the first x-ray and 73610-26-59 (Radiologic examination, ankle; complete, minimum of three views; Distinct procedural service) for the second. Because you'll report two different codes for the separate x-rays, modifier -76 is inappropriate, and modifier -59 better describes the distinct second x-ray.
 
Tip: You should only use modifier -76 if you perform the exact same procedure twice on the same date.