Orthopedic Coding Alert

Although the fluoroscopy codes 76000 and 76001 specifically refer to "physician time," most carriers still require practices to append modifier -26 (Professional component) if the orthopedic surgeon performs the fluoroscopy.

If you report 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) or 76001 (Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]) with your surgical claims, you have probably heard varying guidelines regarding whether you should append modifiers -TC (Technical component) and -26 to your fluoroscopy codes. Many orthopedic practices believe that because these codes refer to "physician time," the physician can report the global fee without any modifiers. This is not the case, however, with most Medicare carriers.

"76000 is not a 'supervision'code," says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., a medical reimbursement consulting firm in Dallas, Ga. "The physician has to perform the fluoroscopy to bill the service." Despite that, most insurers require orthopedists to append modifier -26 to both 76000 and 76001 if they do not own the fluoroscopy equipment.

In 2001, most Medicare carriers directed providers to report 76000 alone, with no modifiers. The Empire Medicare "2001 Medicare Physician Fee Schedule Data Base Quarterly Update," for example, stated, "The professional/technical component indicator is changing from a '1'to a '2'for procedure code 76000. This code is for the physician work portion of the test (professional component). Modifiers -26 and -TC cannot be used with this code."

Despite this and other carriers'directions to stop appending modifiers -26 and -TC to 76000 retroactive to Jan. 1, 2001, however, CMS processed nearly 4,000 claims for 76000 with these two modifiers in 2001 (see "Benchmark Your Fluoroscopy Code Use" on page 43 for more information).

Those orthopedists who didn't heed their carriers'advice to drop the modifiers turned out to be right on track the following year, when carriers reversed their guidelines. Empire's "2002 Medicare Physician Fee Schedule Data Base Indicator Additions and Revisions" states, "The professional/technical component indicator for the following codes changed to '1.'These codes have both a technical and professional component. Modifiers -26 and -TC can be used with these codes." The document lists code 76000 as one of the affected codes.

So how do you know whether your carrier requires modifier -26 with your fluoroscopy claims? Most Medicare carriers'policies specifically direct coders to append modifiers -26 and -TC to 76000 and 76001, but private payers may not follow the same advice.

"Check with your payers to see if they require modifier -26 with 76000 and 76001," says Jan Rasmussen, CPC, president of Professional Coding Solutions, an Eau Claire, Wis., firm that provides coding support, compliance review and contract coding to physicians across the country.

"If they require modifier -26, your next question should be what kind of documentation they require to support reporting 76000. Depending on who is yielding the payment, you may find vastly different interpretations and documentation requirements."

Most orthopedists are familiar with the longstanding adage "Do not bill fluoroscopy separately from your orthopedic surgery." Parman points to the National Correct Coding Initiative (NCCI) guideline that states, "Unless specifically noted, fluoroscopy necessary to complete a procedure and obtain the necessary permanent radiographic record is included in the major procedure performed." If, for example, you require fluoroscopic guidance to reduce a metacarpal fracture and insert internal fixation (26615), your insurer would consider the fluoroscopy an integral part of the procedure.

But what happens when fluoroscopy isn't integral to the surgery but is separate from it?

You may encounter some instances when you can report 76000 and 76001 in addition to your surgical codes. Section 4821 of the Medicare Carriers Manual leaves this issue open to interpretation, stating that the global surgical package does not include diagnostic tests and procedures, "including diagnostic radiological procedures," and physicians should therefore report these services separately.

This does not mean that you should report all of your fluoroscopy services separately from your surgical codes. "The bottom line is that it's OK to code for the fluoroscopy if it isn't an integral part of the procedure," says Paul Kosmatka, MD, orthopedic surgeon at the Marshfield Clinic in Marshfield, Wis.

Your office should establish its own method of communication between the surgeon and the coder to delineate those fluoroscopy services that the surgeon feels are separately identifiable from the surgery. "In our practice, we have a specific method to determine whether the fluoroscopy is separately billable," says Pat Williams, CPC, coder at Advanced Orthopaedic Centers in Richmond, Va.

"If, after a procedure is completed, the fluoroscope is used to check the positioning of an implant, screw, fixation, etc., or to verify that all foreign bodies have been removed, then we separately report the fluoroscopy."

This method, however, should not be taken as one-size-fits-all advice. Each practice should create its own method of determining when it should and should not report fluoroscopy in addition to the surgical procedure. When in doubt, always double-check with the surgeon and ensure that his or her documentation clearly demonstrates the reasons why the fluoroscopy was not integral to the surgery.