Orthopedic Coding Alert

If you perform medically necessary x-rays before and after surgery for instance, to confirm implant or hardware position before finalizing an operation you may be able to report both interpretations to Medicare. Your modifier choice and documentation will help you demonstrate medical necessity for both films.

Orthopedists often order x-rays while in the operating room, but their x-ray interpretations aren't always billable. To determine whether your interpretation is included in the global package, always look at the physician's intent.

Debbie Kopp, biller at Orthopaedic Associates of Great Neck LLP, a Long Island, N.Y., practice, offers the following example:

"Our orthopedist ordered prereduction x-rays and interpreted the films. He then reduced the fracture and ordered postreduction x-rays. He dictated a separate note for each x-ray interpretation. Can we report both pre- and postreduction x-rays?"

What Is the Physician's Intent?

The answer is maybe. "If you order the films to document the 'before and after'condition of the patient's fracture, the films are potentially part of the surgical procedure," says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., a medical reimbursement consulting firm in Dallas, Ga. In this scenario, Parman says, the films simply document the surgical service, in which case you should not report your interpretations separately.

If, however, the films require interpretation and not just because you employ a "we interpret everything" policy then you can report the studies based on the number of views you interpret, Parman says. "Films would require interpretation if the physician could not determine that the fracture is correctly aligned and needs a concomitant interpretation before finalizing the surgery."

In addition, if the orthopedist orders the prereduction x-rays to actually 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 -59 and -76 Make the Difference

Suppose you interpret a medically necessary two-view study of the patient's ankle before surgery to confirm the fracture site and a three-view study during surgery to  ensure that you aligned the fracture correctly. You should report 73610-26 (Radiologic examination, ankle; complete, minimum of three views; Professional component) followed by 73600-26-59 (Radiologic examination, ankle; two views; Professional component; Distinct procedural service).

Modifier -26 tells the insurer that you performed only the professional portion of the x-ray (the hospital probably performed the technical component and will append modifier -TC [Technical component] to its x-ray claims).

Modifier -59 is necessary to demonstrate that the ankle x-rays are separate and distinct from one another, and tells the insurer that both were medically necessary.

Modifier -76 Signifies Repeat

If you interpret medically necessary two-view studies both before and after the surgery, you should report 73600-26, followed by 73600-26-76. Modifier -76 (Repeat procedure by same physician) tells the insurer that you performed the same procedure twice.

Note: If the physician interprets both sets of films after completing surgery, you should count the x-rays as surgical documentation and they are therefore not separately billable, Parman says. Reading the films after surgery indicates that you ordered and interpreted the x-rays for documentation purposes; if they were integral to the surgery, you probably would have read them during the procedure.

New Dx May Warrant Reinterpretation

A patient presents to your office for follow-up after an emergency department (ED) physician diagnoses her with a sprained wrist. You review the ED x-rays, examine the patient's wrist and advise the patient to return in two weeks if pain persists.

As we reported in the October 2002 Orthopedic Coding Alert, you cannot separately report such x-ray reviews, because "the orthopedist gets credit in the medical decision-making (MDM) portion of his or her E/M service for reviewing diagnostic studies," says David McKenzie, director of reimbursement for the American College of Emergency Physicians in Irving, Texas.

But what if the orthopedist reviews the films and discovers an undiagnosed condition, such as a fracture, on the films? "This falls under the Medicare guideline that allows a second interpretation payment for a legitimate second opinion or findings related to a different diagnosis and treatment," McKenzie says. "The orthopedist can bill for his or her interpretation of the film because it contributes to the diagnosis and treatment of the patient."

Unless you and the ED physician interpret the x-ray on the same date of service, you should not append modifier -77 (Repeat procedure by another physician) to your interpretation claim. Instead, you should report 73110-26 (Radiologic examination, wrist; complete, minimum of three views) with the wrist fracture diagnosis (814.0x-814.1x).

Because the ED physician reported his interpretation with a wrist sprain ICD-9 code (842.0x), the insurer should note the separate diagnoses and pay both claims. Some payers, however, will reject your claim as a duplicate based on the patient's accident date. Therefore, you should submit a paper claim along with a letter explaining why you repeated the x-ray interpretation.

Modifier -77 Applies to Same Date

You can append modifier -77 to repeat procedures if you and the other physician perform them on the same date of service. For instance, a trauma patient presents to the ED with a broken arm (813.23, Fracture of radius and ulna, shaft). The ED physician reviews the x-ray (73090-26, Radiologic examination; forearm, two views) and diagnoses a fracture. The orthopedist applies a cast and orders a repeat x-ray to confirm that the bone is set correctly under the cast.

The orthopedist should report 73090-26-77 for his interpretation because another physician performed the initial x-ray reading.

Distinguish Review From Interpretation

Medicare makes a clear distinction between a separate x-ray interpretation (which would necessitate appending modifier -26) and a simple "review," which the orthopedist would include in his or her E/M service for the day.

Section 15023 of the Medicare Carriers Manual (MCM) advises practices to distinguish between an actual x-ray "interpretation and report" and a simple "review" of the procedure.

The MCM states, "A professional component billing based on a review of the findings of these procedures, 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 since the review is already included in the emergency department evaluation and management (E/M) payment."

For example, the MCM suggests that a notation in the medical records saying "fractured tibia" would not suffice as a separately payable interpretation and report of the procedure "and should be considered a review of the findings payable through the E/M code. An 'interpretation and report'should address the findings, relevant clinical issues, and comparative data (when available)."