Orthopedic Coding Alert

Question: We recently saw a patient who injured his leg in a car accident. The surgeon ordered an x-ray of the affected leg, along with comparison views of the other leg. The insurer denied the x-ray claim for the unaffected leg and only paid us for a unilateral x-ray. Should we appeal?

Alabama Subscriber

Answer: Probably not. Although your payer may reimburse comparison views of children’s legs, you can’t usually collect for comparison views that you take of adult patients. This depends on the injury. If the physician images the opposite leg to determine leg length (in event of a fracture), you may be reimbursed for this. However, in this scenario, this is unlikely.

Surgeons sometimes order comparison views of children because they suspect growth-plate injuries, and comparing the left side to the right can confirm this type of injury. But in an adult patient, the insurer sometimes considers the non-injured side a screening x-ray because you lack the appropriate diagnosis to justify medical necessity on the healthy leg.

If your physician believes that he requires the comparison view for medically necessary reasons, you should submit the claims with the LT (Left side) and RT (Right side) modifiers, and include a letter in which the physician describes the medical necessity for the unaffected side. He should link the x-rays to V72.5 (Radiological examination, not elsewhere classified).

ICD-10: When your diagnosis system changes, you will report Z01.89 (Encounter for other specified special examinations) instead.