Orthopedic Coding Alert

If you can't distinguish a spot film from a standard x-ray, read this

Orthopedic coders have to remember scores of coding rules, from fracture care to surgery coding to disease management. In addition, orthopedic practices face radiology coding challenges every day, because imaging is an integral part of good surgical care.

If you occasionally find radiology coding tricky, the answers to the following five questions may help you submit your claims with fewer headaches and better reimbursement odds.

Look to NCCI for Intraoperative Imaging Guidelines

Question 1: When is it appropriate to report interpretation of intraoperative images? And if we can bill these, what is the proper way to code these services?

Answer 1: Under the National Correct Coding Initiative edits, fluoroscopy (76000, Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) is bundled into many orthopedic procedures. For example, fluoro is a component of 25565 (Closed treatment of radial and ulnar shaft fractures; with manipulation). When fluoro is defined as a Column 2 code, do not apply a modifier to override the NCCI edit unless the fluoro was performed during a separate encounter or on a separate part of the body.

If fluoro is not defined as part of the procedure (either by the CPT code definition or by the NCCI edits), you can report 76000 when the orthopedist supervises and interprets the fluoroscopy during an operative procedure. The physician must document that fluoro was used and what it revealed. Be sure to use modifier 26 (Professional component) if the fluoro was performed in the hospital setting.

If permanent x-ray images are captured (either on film or in a PACS system) for diagnostic purposes and these images are interpreted by the orthopedist, you can report the code for x-ray exam of the body area--for example, 73090 (Radiologic examination; forearm, two views). For example, a diagnostic x-ray exam would typically be performed at the conclusion of the surgery to confirm the result. If you charge for an x-ray interpretation, be sure the orthopedist has dictated an interpretive report.

Although the physician's interpretation can be included in the surgical op report, you must maintain complete documentation of the x-ray findings. According to the Medicare Claims Processing Manual, Chapter 13, Section 100.1, -A professional component billing based on a review of the findings . . . without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service.-

Also, always remember to apply modifier 26 (Professional component) if the physician performs the service in a hospital setting.

Some professional organizations have stated their position on these services. For example, the American Society for Surgery of the Hand's (ASSH) Global Service Information Book for Hand Surgeons lists the following as included in surgical procedures: -Intra-operative photo(s), video imaging, and other imaging techniques; intra-operative supervision and interpretation of imaging by operating surgeon.-

But the America Academy of Orthopaedic Surgeons (AAOS), in its Complete Global Service Data for Orthopaedic Surgery, lists as the items included in the global service package, -intraoperative photos and/or video recording, excluding ionizing radiation.- Ionizing radiation includes x-rays and fluoroscopy.

However, as discussed above, you should not report the fluoro if it is bundled into the surgical procedure under the NCCI edits.
 
Because the ASSH and AAOS publish slightly different statements on this, you should always first check the NCCI edits and then your payer's policy before you bill for radiologic guidance.

Physician Should Personally Supervise Fluoro

Question 2: Aren't 76000 and 76001 for -physician- time administering fluoroscopy? In most cases, the physician isn't personally administering the fluoro.
 
Can we still report 76000 if the tech uses the fluoroscopy machine?

Answer 2: Codes 76000 and 76001 (Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]) are defined in terms of physician time.

As with any imaging code, the physician does not have to personally operate the fluoro machine, but he is required to supervise the technologist who is operating it and must interpret the images. The op report should indicate that fluoro was used and what the findings were.

Ask Payer for Spot-Film Requirements

Question 3: My insurer says that -spot films- are not separately reimbursable during fracture repairs, but we don't know the difference between spot films and payable x-rays. Would you tell us the difference?

Answer 3: Spot films are x-ray images captured during fluoroscopy. Your payer apparently considers spot films to be part of the operative procedure rather than a separately billable diagnostic x-ray exam. The payer will probably be willing to reimburse for the x-rays that are taken at the conclusion of the fracture repair (to confirm that the reduction is satisfactory). But to be on the safe side, you should ask the payer for written clarification.

X-Ray Codes Require Permanent Images

Question 4: One of our hand surgeons recently brought a fluoro (mini C-arm) into the office on a trial basis. He has done a few motion studies, and one with stress views, but it appears that he is most often using the unit for x-ray views because he says he has the results instantly. I know this is similar to an x-ray service, but I don't think we can use an x-ray code because there are no films. However, I don't think we can use 76000 for an x-ray. How should we code this?

Answer 4: You-re correct that the regular x-ray codes (for example, 73120, Radiologic examination, hand; two views) should not be used if the physician is not capturing permanent images, either on film or in a PACS system. But it would also be incorrect to report 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) if the physician is using the C-arm simply to take a quick look at the patient's anatomy on the fluoro screen.

Code 76000 should be used when it's medically necessary for the physician to evaluate motion of a joint or other structure. You-ll notice that 76000 pays more than many of the skeletal x-ray codes (for example, 73100, Radiologic examination, wrist; two views).

If medical necessity requires the physician to perform an x-ray, and not standard fluoroscopic guidance, the best solution would be for the physician to take a film or PACS image and report the service with the regular x-ray codes. 

-Minimum 2 Views- Includes 3 Views

Question 5: Our surgeon always performs three views of the shoulder (sometimes four views) and we have been billing a unit of 73030 along with 73020-59 to reflect the three views. We have gotten paid for these with some payers, but our office manager told us that this is incorrect. Is she right? And if so, how should we report three shoulder views?

Answer 5: Code 73030 is defined as -Radiologic examination, shoulder; complete, minimum of two views.- That means you can use this code for two or more views. In this case, report only 73030 for three views of the shoulder. Don't assign 73020-59 (Radiologic examination, shoulder; one view; Distinct procedural service) together with 73030 to represent the third view. 

This is explained in the CMS National Correct Coding Policy Manual, Chapter 9: -CPT code descriptors which specify a minimum number of views should be reported when the minimum number of views or if more than the minimum number of views must be obtained in order to satisfactorily complete the radiographic study. For example, if three views of the shoulder are obtained, CPT code 73030, one unit of service, should be reported, not 73020 and 73030.-

Jackie Miller, RHIA, CPC, is a senior coding consultant at Coding Strategies Inc. in Powder Springs, Ga.