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 [...]