Podiatry Coding & Billing Alert

Hint: Don’t bill for ‘comparison views’ in most cases.

X-rays can be an important part of the diagnostic process for a variety of podiatric conditions, but coding these radiological studies can be challenging. After all, CPT^® includes hundreds of codes in its Radiology Services section, and the rules surrounding these codes can be mired in complexity.

So, to make things simpler, we’ve put together five podiatry-specific X-ray scenarios to help you secure reimbursement for X-ray procedures.

Code by Descriptor, Not by Units

When your podiatrist performs injections or other procedures, you’re accustomed to reporting the most accurate CPT^® code with the number of units next to it on your claim form. Two injections? You’re likely to bill two units. However, you can remove that coding convention from your vocabulary when you’re reporting the X-ray codes.

Here’s why: CPT^® created the verbiage in the X-ray descriptors so they describe the specific number of views included in each code. Therefore, you should not be billing the number of views taken in the units field of your claim form. Instead, you should select your X-ray code based on the number of views taken and report the service as only one unit.

Scenario 1: The podiatrist sees a female patient who has been having trouble walking for three months, following an accident when her walker slipped out from under her and she fell down and caught her left foot under the weight of her body. The patient says the pain is on the left, right, and middle of her foot and is not confined to one area. The podiatrist orders four views of the patient’s foot: dorsoplantar, medial oblique, lateral, and canale — resulting in a four-view X-ray of the left foot.

In this situation, you should report one unit of 73630 (Radiologic examination, foot; complete, minimum of 3 views). Even though the podiatrist ordered more views than what’s described in the code, the fact that the descriptor says “minimum of” shows that as long as you report three views, this is the code that applies. More views would be included in the payment for 73630.

Document X-Ray View Types, Not Just Quantity

One wrinkle to the above rule is that you cannot simply select a particular code based on the podiatrist or radiology tech’s description of how many views they performed. You must also know the types of views that were taken.

Scenario 2: Suppose a patient presents with foot pain after closing their foot in the car door, and the podiatrist suspects a fracture and orders X-rays. The radiology tech documents a two-view radiologic examination.

In this case, you don’t know if the radiology tech performed two views of the same location, or two views of different locations, because they didn’t document the type, and you therefore cannot report 73620 (Radiologic examination, foot; 2 views).

If, however, the documentation said, “Performed dorsoplantar and lateral projections of the foot to evaluate for trauma and fractures,” then you can justify reporting 73620.

Expect Denials With Comparison X-Rays

If your podiatrist is curious about whether a patient’s issue is due to injury or disease versus just occurring due to how their body grew, they may ask for “comparison” X-rays. In these situations, the podiatrist will order films of both feet to compare the painful foot to the healthy foot.

However, most payers will not reimburse you for these types of X-rays when you perform them in adult patients. Some insurers will cover comparisons in children to evaluate for growth plate injuries, but that’s not the case with adult patients. For instance, Blue Cross and Blue Shield of Minnesota’s policy states, “Contralateral unaffected body part X-rays taken for comparison purposes are not covered” (https://www. bluecrossmn.com/sites/default/files/ DAM/2020-07/Radiology 001_ Radiology Services_General Guides 01.09.18.pdf).

Scenario 3: A 23-year-old male patient presents to your practice with a left foot injury that he sustained while bicycling. The podiatrist orders comparison views of the left and right feet. In this case, talk to the podiatrist and let them know the insurer is not likely to pay for the right foot X-ray due to a lack of medical necessity. Ask them if they’d like to proceed with the X-rays knowing that only the right one will be reimbursable.

Use Modifiers for Repeat Surgical X-Rays

In some cases, the podiatrist will order prereduction X-rays before surgically reducing a fracture, followed by postreduction X-rays as well. But if you order the films to document the “before and after” condition of the patient’s fracture, your insurer will probably bundle the films into the reduction.

If, however, the podiatrist orders the prereduction X-rays to diagnose the fracture and subsequently orders postreduction films to confirm alignment, your insurer should reimburse both interpretations, as long as the physician documents the services appropriately and you use appropriate modifiers.

Scenario 4: Suppose you interpret a medically necessary two-view study of the patient’s ankle in the morning to diagnose the fracture site and another two-view study following afternoon surgery to ensure that you aligned the fracture correctly. You should report 73600 for the first view, followed by 73600 appended with modifier 76 (Repeat procedure or service by same physician…) for the second.

Avoid Billing Double X-Ray Interpretations

Your podiatrist may not always be the first doctor a patient sees after having an issue, and in some instances, the patient may bring their own X-ray to your practice along with another doctor’s interpretation of it. If your podiatrist chooses to perform another X-ray interpretation, you can’t bill for it, because someone else already billed that to the payer. Instead, you should count your podiatrist’s re-read toward the medical decision making (MDM) portion of the E/M for that visit.

Caveat: There are some rare instances when you can bill for the professional component in cases like this.

Scenario 5: Suppose a new patient complaining of foot pain presents with X-rays that come with an interpretation indicating that the patient has nothing wrong with them. However, when the podiatrist reviews the films, they disagree with the previous interpretation and diagnose the patient with a stress fracture. In this case, the podiatrist can write their interpretation and bill that to the insurer with modifiers 77 (Repeat procedure by another physician…) and 26 (Professional component) appended.

On these types of claims, you should send the insurer both interpretations (the radiologist’s and the podiatrist’s), along with documentation highlighting the differences between the interpretations.

Remember: Modifier 26 tells the insurer that you performed only the professional portion of the service — the interpretation of the X-ray. In all the other scenarios, the codes used presume that you are billing for both the professional and technical — the portion of the service involving the actual use of the X-ray machine to create images — components of an X-ray service. If you take the X-rays at another facility, such as a hospital that owns X-ray equipment, and your practice has not taken the images on equipment you own, you can only bill for the professional component.