Primary Care Coding Alert

Question: If my family physician orders an x-ray and provides personal, independent visualization of the image, how many points should I add to the E/M level?

Florida Subscriber

Answer: You should add points to an E/M level based on medical decision-making elements during the visit as long as the physician doesn't also submit a bill for x-ray interpretation.

For example, your FP orders an x-ray (71010, Radiologic examination, chest; single view, frontal). That means your physician can add one point to the E/M service for ordering a radiological test in CPT's radiology section. If the physician reviews the report on the next visit, he can receive one point for reviewing the radiological test. And, when the FP personally views x-ray  films, the physician can add two points to the E/M's medical decision-making.