Primary Care Coding Alert

Use modifier -59 for separate sides

It's official: You should code a finger or a hand x-ray, but not both if the exams occur on the same hand. Otherwise, modifier -59 is your license to unbundle.

The National Correct Coding Initiative (NCCI) version 9.3, effective Oct. 1, bundles four x-ray codes (73140, 73660, 73560 and 73562) into their related anatomic components (73120-73140, 73620 and 73565). When your family physician (FP) performs the x-rays on separate sides, Medicare permits you to use modifier -59 (Distinct procedural service) to override the edits.

Bill Different Hand and Finger Exam

If your FP performs in-office x-rays, you shouldn't separately report a finger x-ray (73140, Radiologic examination, finger[s], minimum of two views) with a hand exam (73120, Radiologic examination, hand; two views; 73130, ... minimum of three views) on the same side.

These edits make sense, says Patricia Davis, CPC, business office supervisor and radiology x-ray technician at Middlesex Health System Primary Care in Middletown, Ct. The hand x-ray shows all five fingers. "So no reason exists to perform a hand and finger x-ray on the same hand," she says.

For instance, after taking up boxing, a patient presents to an FP's office complaining of finger and hand pain on his right hand. The FP orders a hand x-ray with three views (73130). In this case, you shouldn't unbundle the finger x-ray (73140) from the hand x-ray (73130), Davis says. The hand x-ray includes the fingers, she adds.

NCCI uses the same rationale to bundle a two-view hand x-ray (73120) with a finger x-ray (73140). Because the hand x-ray shows the fingers, a FP would not need to perform 73120 at the same encounter on the same hand.

When your FP performs the finger x-ray on a different anatomic site from the hand exam, you should use modifier -59 to indicate that the FP performed the x-rays on separate sides. "When NCCI bundles two procedures that occur on different body sites, you need modifier -59 to unbundle the codes," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Landsdale, Pa.

In this case, appending modifier -59 to 73140 will unbundle the finger x-ray (73140) from the hand x-ray (73120-73130).

In addition, make sure you use the proper body-side modifiers (-LT, Left side; -RT, Right side) to inform the payer that the FP examined different sites, Davis says.

Suppose the amateur boxer in the above example also injures his left pointer and middle fingers. In addition to the three-view right-hand x-ray, the FP performs and interprets a two-view finger x-ray on the patient's left hand. You should assign 73130-RT for the hand x-ray. For the finger x-ray, you should append modifier -59 to 73140-59-LT to indicate that the finger exam occurs on a separate anatomic site from the hand x-ray.

Code Other-Side Toe and Foot X-Ray

Like the upper-extremity edit, you may report two lower-extremity codes, 73660 (Radiologic examination; toe[s], minimum of two views) and 73620 (Radiologic examination, foot; two views), only when your FP performs the x-rays on separate feet. Since a same-side foot x-ray will also show the toes, NCCI bundles 73660 into 73620.

"These edits follow the same principle as the finger-hand bundle," Davis says. You would perform either a toe or a foot x-ray, not both. Most practices are following these billing guidelines, so the bundles shouldn't affect your bottom line, she says.

Unbundle 1-3 Views From Different-Sided 73565

 When your FP performs knee x-rays in the office, don't report 73560 (Radiologic examination, knee; one or two views) or 73562 (... three views) with 73565 (... both knees, standing, anteroposterior). Payers that follow NCCI now consider one to three knee x-ray views (73560-73562) part of 73565.