Pulmonology Coding Alert

Curious about how to code a chest X-ray when a line is placed? Find out here.

If you’ve seen one chest X-ray chart, you’ve seen them all, right? Not so fast. It may be easy to report a standard chest X-ray with one or two views, but when the physician also requires tube and line placement imaging, you can quickly move beyond the standard radiology codes in this category.

That’s because there’s a few important variables you’ve got to take into consideration in order to stay compliant on your tube and line placement imaging report. These variables include bundling edits and a specific set of instructions outlined within the National Correct Coding Initiative (NCCI) Policy Manual

Read on to get a hang of these fundamental guidelines and incorporate them into a few clinical examples.

Incorporate This NCCI Policy Manual Guideline

When considering whether to report a chest X-ray performed during or after a chest tube or catheter placement, you’ll want to have a look at this NCCI guideline located in chapter nine of the NCCI Policy Manual:

“When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly, when an emergency endotracheal intubation procedure (CPT^® code 31500), chest tube insertion procedure (e.g., CPT^® codes 32550, 32551, 32554, 32555), or insertion of a central flow catheter procedure (e.g., Swan-Ganz) (CPT^® code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT^® codes 71045, 71046) shall not be reported separately.”

After reading this, you might feel that you’ve got a definitive answer to the question of whether you should report a chest X-ray with an initial catheter or tube placement. However, there’s a little more to the story than what’s included in this guideline.

Use NCCI Guidelines in Appropriate Context

You’ve got to look at this guideline in the context of the provider performing the placement procedure and the provider performing the imaging. In order to simplify the process, you’ll want to make sure your coding considerations are based on what national provider identification (NPI) is billing for what service.

If, for example, the same provider that performs the line placement is performing and interpreting the follow-up chest X-ray, then you may not bill separately for a chest X-ray. The NCCI guidelines above are specific to scenarios such as this. These scenarios may occur in interventional radiology settings where the same provider that performs the line placement performs the follow-up imaging to check placement.

Distinguish Between Fluoroscopic Guidance and Follow-Up Imaging

“It’s important to distinguish between two different types of imaging,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “During the placement of the line, the physician will typically utilize fluoroscopic imaging in order to guide the catheter into position. On the other hand, the patient will receive an X-ray following the procedure in order to confirm proper positioning,” Rosenberg explains.

Fluoroscopic guidance will be either included in the line placement CPT^® code (eg, 32555), or will be billed out separately by the performing physician (eg, 75989). If the same physician performs the placement, fluoroscopic guidance, and chest X-ray interpretation, you will abide by the aforementioned NCCI policy and consider the chest X-ray bundled into the line placement.

Use These Tips for Follow-Up Line, Tube Placement Imaging

In other instances, you’ll be tasked with coding a patient encounter in which the provider has already performed the initial follow-up X-ray for the placement or intubation. These sorts of procedures often require numerous secondary X-rays to reaffirm that the positioning of the catheter or tube is sound when the patient develops symptoms that could raise questions about the equipment functionality.

However, you’ll want to consider a few variables. First, you’ll want to have a look at the patient’s ledger to determine whether this secondary X-ray was performed on the same day as the initial procedure and X-ray. If so, and if the provider is the same, you will want to append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to every subsequent chest X-ray on the same day.

Remember: If a subsequent chest X-ray performed on the same day differs in views from the first chest X-ray performed, you do not need to append modifier 76. “These modifiers require the repeated CPT^® codes to be the same,” says Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG, Inc. Consulting in Raleigh, North Carolina. “However, you should report modifier 59 [Distinct procedural service] or modifier XE [Separate encounter…] to indicate that the chest X-rays were performed in separate sessions/encounters on the same date of service,” Goodman details.