Orthopedic Coding Alert

Orthopedists make routine use of x-rays as part of good healthcare practice, sending patients to outside facilities for x-rays to be taken, taking them in-house, examining x-ray film that patients provide or ordering x-rays at the emergency department (ED). X-ray procedures present certain challenges to the orthopedic coder, who must take a variety of circumstances into account when billing for them.

Codes for x-rays and other radiological services describe both the technical and professional components of the procedures.
 
The technical component includes labor and supplies (such as the built-in costs for equipment and film), as well as the fee for the technician who takes the x-rays. When a facility is responsible for the technical portion of a service only, that service or test (e.g., 72010, Radiologic examination, spine, entire, survey study, anteroposterior and lateral) is billed with modifier -TC (Technical component).
 
Note: Although modifier -TC is a CMS modifier and is required for Medicare claims, it may not be accepted for non-Medicare claims. 
 
The professional component includes the physician's work and overhead expenses covering interpretation of diagnostic tests, diagnostic and therapeutic radiology and pathology services. When the physician merely interprets the x-ray, append modifier -26 (Professional component) to the x-ray code.

If a patient presents to an orthopedist with neck pain, the physician is likely to order an x-ray of the affected area and code 72040 (Radiologic examination, spine, cervical; two or three views), 72050 ( minimum of four views) or 72052 ( complete, including oblique and flexion and/or extension studies).
 
An orthopedist may send a patient to an outside facility where a radiologist takes x-rays, interprets them and sends his or her assessment and the film(s) to the orthopedist. "Orthopedists may feel entitled to bill for a second radiological interpretation when the first was done by a radiologist, because they always review the films themselves and may or may not agree with the radiology report," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University
Orthopedic Associates in New Brunswick, N.J.
 
Coders often misunderstand modifier -26 and try to append it to the x-ray code in these cases. Although the orthopedist will no doubt look at the films when following up with the patient, chances are this service is included in the E/M visit (99211-99215, Office or other outpatient visit ...).
 
"If the physician provides the first reading of these films and prepares a signed radiology report," adds Stout, "only then can he or she bill for the professional component." Otherwise, reviewing x-rays is considered part of the E/M service when the physician is viewing films taken before the visit. Since an official radiological report already exists, there is no additional professional component that can be billed.
 
X-ray review falls under CPT's guidelines for the medical decision-making component of an E/M service (i.e., "the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed"). Simply reviewing films taken elsewhere does not entitle a physician to report the professional component of an x-ray study. However, if the physician reviews outside films and their accompanying interpretation, disagrees with the findings and prepares his or her own written x-ray report, this constitutes a significant over-read of the films and it may be appropriate to bill for the interpretation. 
 
Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., adds that the only way to circumvent this coding rule is to have a written agreement with the radiology lab that it will not provide the professional component or interpretation of the x-rays. "If you have an agreement with the lab saying that your practice is responsible for the initial reading," says Brink, "then you can bill for both the E/M service and the professional component." But practices may run into resistance when approaching radiology labs with such a deal in hand, since taking services away from them cuts into their bottom line.

The most straightforward coding solution for x-rays and orthopedists comes when the practice has an in-house x-ray facility. When a physician orders x-rays, notes Jennie Horner, CPC, lead biller and coder at Southern Ohio Medical Center Medical Care Foundation in Portsmouth, Ohio, it's merely a matter of the patient walking down the hall to have them taken. Since the x-ray technician is on staff and the orthopedist does the first reading of the films, the practice bills the x-ray code (e.g., 70360, Radiologic examination; neck, soft tissue) without modifiers.

Patient-Supplied Films

If a patient is referred from one physician to another for an orthopedic problem, the patient may present with x-rays in hand.
 
For example, a chiropractor treating a patient for neck pain would order and interpret x-rays of the affected area. If the patient's symptoms persisted after several visits, the chiropractor would refer the patient (with films) to an orthopedist for further evaluation.
 
The initial visit to the orthopedist would bear a consultation code (99241-99245, Office consultation for a new or established patient). Although the orthopedist will do a fresh evaluation of the films, x-ray interpretation is included as part of the E/M service.
 
Any other diagnostic tests the orthopedist orders, such as a magnetic resonance image (MRI) or computerized axial tomography (CAT) scan, are billed separately (provided they are done in-house).

When orthopedists are called to the ED to treat a patient, they are unlikely to obtain any coding credit for interpreting x-rays.
 
If a patient reports to the ED with a suspected fractured wrist, for example, the ED physician is likely to order an x-ray. A hospital radiologist would x-ray the wrist (e.g., 73100, Radiologic examination, wrist; two views, or 73110, complete, minimum of three views), interpret the x-rays and submit a written report and the films to the on-call physician before the orthopedist arrives at the hospital.
 
Although the orthopedist will look at the x-rays before rendering care, his or her interpretation is generally not a billable service. The orthopedist can bill for the visit to the hospital instead, using a code from the 99241-99245 (Office consultation for a new or established patient...) series and modifier -57 (Decision for surgery) since he or she will set the fracture. The orthopedist can also bill the appropriate fracture care code (e.g., 25635, Closed treatment of carpal bone fracture [excluding carpal scaphoid (navicular)]; with manipulation, each bone) for treatment of the fracture. 

The exception to this rule may generate controversy in the radiology department: CMS offers the orthopedist the chance to bill for the interpretation in the ED setting. Medicare Carriers Manual section 15023 states, "When you receive multiple claims for the same interpretation, generally pay for the first bill received. Pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient." If the orthopedist arrives in the ED before the radiologist has read the films, views the films, diagnoses and treats a fracture and dictates a report of the interpretation of the films, he or she can report the x-ray code with modifier -26.
 
Since the orthopedist will be responsible for follow-up care with the patient, subsequent visits to the orthopedist's office would be considered part of the global service package for 25635.