Podiatry Coding & Billing Alert

Using foot and toe modifiers correctly can be the key to reimbursement.

Even beginning coders can tell you that the foot is an amazingly complex structure. So it stands to reason that X-raying the foot can cause all sorts of coding confusion. Take heart: Our expert advice will help you get a firm footing.

More Toes Than Codes

The six primary X-ray codes podiatrists encounter are:

• 73600 -- Radiologic examination, ankle; two views
• 73610 -- ... complete, minimum of three views
• 73620 -- Radiologic examination, foot; two views
• 73630 -- ... complete, minimum of three views
• 73650 --Radiologic examination; calcaneus, minimum of two views
• 73660 -- ... toe(s), minimum of two views.

Podiatry offices most frequently use codes 73620 and 73630. Unlike what you find with many other CPT® codes, radiology codes aren't bundled with any other nonradiology procedures. But there is, however, a National Correct Coding Initiative (NCCI) edit that affects them: You cannot bill 73620 with 73660, experts say -- the reason being that an X-ray of the toe will show up on the X-ray of the foot.

However, the edits have a status indicator of "1," meaning they can qualify to be unbundled in certain situations.

How it works: All edits consist of code pairs that are arranged in Column 1 and Column 2, explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. Status indicator "1" allows the payment of the Column 2 code if performed on the same day on the same patient by the same provider as the code listed in Column 1.

For example, if a patient has heel pain in both feet and it's suspected that the patient has a fractured toe, an AP X-ray of the toe and then a lateral X-ray of both feet can diagnose plantar faciitis. Modifier 59 (Distinct procedural service) is appropriate because you are taking a bilateral X-ray of the foot and one X-ray of the toe.

To Bill or Not to Bill Bilateral

When billing X-rays, the question often arises whether a podiatrist should bill bilateral X-rays using RT (Right side), LT (Left side), or 50 (Bilateral procedure). Most insurance carriers will accept either for bilateral claims -- one code with modifier 50 appended, or two codes with LT and RT.

With Medicare, to indicate which foot, you can only append to X-rays modifiers LT and RT, or if it's a toe X-ray, one of the toe modifiers, like T3 (Left foot, fourth digit).That there may be some private carriers that require modifier 50; check with the insurance carriers as to what they prefer.

Another trap to avoid is billing an X-ray with modifier 50 with two units of service. Coding that way is technically billing for four units -- not for a right and left foot.

Tip: Don't append LT or RT on top of a toe modifier -- the toe modifier already indicates which foot the toe is on.

Technical Versus Professional

Sometimes X-rays are taken and evaluated by different parties. For example, if a radiologist takes the X-ray but does not interpret it, he only bills the technical component of the X-ray using modifier TC (Technical component). The X-ray is then read and interpreted by the podiatrist, who would bill the professional component of the X-ray using modifier 26 (Professional component). If your office takes its own X-rays, you may not unbundle the code and bill the components separately.

You should not use 26 when billing any X-ray viewing that is a second interpretation of an X-ray. In this case, reviewing the X-ray is billed as part of an office visit under an E/M code because the podiatrist is really just evaluating the condition. The X-ray review (worth two points of medical decision making) may increase the E/M level because of the time required to evaluate the X-rays and determine treatment.

Confusion With Consultation and Comparisons

Don't be tempted to bill 76140 (Consultation on X-ray examination made elsewhere, written report) for a second opinion of a patient's films. This code is only used when a physician requests a second opinion from another physician specifically on an X-ray study, and there is no face-to-face time with the patient. If the review is for a second surgical opinion, you could bill the review as an E/M consultation or as Hoffman does, as a second opinion.

Comparison X-rays are a little trickier. A podiatrist might order bilateral X-rays of the feet in order to compare the symptomatic foot to the nonsymptomatic foot.

Because the comparison involves X-raying an unaffected foot, comparison views are considered "screenings" by Medicare and are not usually covered (mammograms and colorectal cancer screenings are examples of exceptions). If the podiatrist orders such a set, be prepared to argue medical necessity.

Avoid Denials With This Trick

The biggest problem that some offices face with X-ray denials is when the insurance company says the patient's diagnosis did not warrant the taking of three views of the patient's foot.

To avoid this, some coders try to get the podiatrists to really consider how necessary that second or third view is before they order it. If three views are needed (say the patient had a hammertoe, a bunion, and a heel spur), justifying the three views in the documentation line of the claim can help avoid this denial.