Radiology Coding Alert

In last month’s article “Decide When to Bundle, Combine Imaging Codes Using this Guide,” you covered an area of radiology coding that is often neglected within the specialty — the concept of bundling versus combining codes.

Now that you’ve got a firm hang on understanding when and how to identify code-combining scenarios, your skills will be put to the test as you cover a broad range of examples.

Take a look at these four real-world scenarios, in which you’ll have to exhaust all your resources to decide whether to combine, bundle, or bill separately.

Refer to CCI Edit, Modifier 59 Guidelines for 74176/74177 Coding

Example 1: Same physician performs computed tomography (CT) abdomen/pelvis with contrast, CT abdomen/pelvis without contrast at different encounters on the same day.

In the case of 74176 (Computed tomography, abdomen and pelvis; without contrast material) and 74177 (Computed tomography, abdomen and pelvis; with contrast material[s]), the first point of reference you want to check is the National Correct Coding Initiative (NCCI) edit between these two codes. As you will see, NCCI edits automatically bundle 74176 into 74177 under a modifier “1” status — meaning that the bundle can be overridden with a modifier under the appropriate circumstances.

Your decision to either use a modifier or bundle 74176 into 74177 depends on the circumstances of the patient encounter. If the provider performs each exam for separate diagnostic reasons, the answer is as simple as applying modifier 59 (Distinct Procedural Service) to 74176 (column 2 code). However, it’s not just diagnostic criteria that allow for the use of modifier 59. CMS states the following as valid reasons to report a claim with modifier 59:

• “Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”

Since the provider performs the second scan at a different session than the first, you are eligible to apply modifier 59 to 74176 in this instance. Depending on your payer policies, you may want to consider the use of the X{EPSU} modifier set in place of modifier 59. Modifier XE (Separate Encounter), for instance, is specifically designated to distinguish separately performed services on the same day.

Recall: In last month’s article “Decide When to Bundle, Combine Imaging Codes Using this Guide,” you covered the example of 74150 (Computed tomography, abdomen; without contrast material) and 74160 (Computed tomography, abdomen; with contrast material(s)) performed on the same day. Since these two codes have a modifier “0” status between them, you cannot code them together under any circumstances. In this case, you will merge the two studies into 74170 (Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections).

Know When to Channel NCCI Policy Manual Guidelines

Example 2: During the same encounter, the provider performs a two-view cervical spine X-ray and a two-view scoliosis study of the entire spine.

For this example, you can refer directly to chapter 9 of the NCCI Policy Manual:

• “If a physician performs a procedure described by CPT^® codes 72081-72084 and at the same patient encounter performs a procedure described by one or more other codes in the CPT^® code range 72020-72120, the physician shall sum the total number of views and report the appropriate code in the CPT^® code range 72081-72084.”

According to these guidelines, the coding for this one is simple. Instead of coding 72040 (Radiologic examination, spine, cervical; 2 or 3 views) and 72082 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views) separately, you will combine the views of both services into one cumulative code, 72083 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views).

Combine Knee X-rays in This Specific Scenario

Example 3: The provider performs a bilateral standing knee X-ray and a bilateral three-view X-ray of the knees during the same patient encounter.

Here, you’re presented with another scenario in which it’s appropriate to combine views into one comprehensive code. As you will see with an NCCI edits check, code 73562 (Radiologic examination, knee; 3 views) is bundled into code 73565 (Radiologic examination, knee; both knees, standing, anteroposterior). Assuming both the same encounter and same diagnostic reason for each exam, you should not consider reporting these separately.

Instead, you will sum the number of views and report the following codes:

• 73564-RT (Right side)
• 73564-LT (Left side)

Think Twice Before Summing Chest X-ray Views

Example 4: A patient arrives for a scheduled two-view chest X-ray in the morning due to recent complaints of pain and tightness in the chest. The patient returns to the emergency room (ER) the same day for complaints of chest pain, and the same physician performs a one-view chest X-ray.

You can refer back to the guidelines on modifier 59 when considering how to report this case study. At first, you may consider two options: Abide by the NCCI edit between codes 71405 (Radiologic examination, chest; single view) and 71046 (Radiologic examination, chest; 2 views) or combine views into 71047 (Radiologic examination, chest; 3 views).

“In this scenario, you should report codes 71045 and 71046-59,” says Toni Jones, RCC, CPC, medical coder at Owensboro Health Regional Hospital Professional Coding in Owensboro, Kentucky. “Since the patient »» was seen at separate encounters, you should not sum the number of views,” Jones explains.

Furthermore, you should only consider summing the views of two separate X-ray procedures if the same provider performs the services at the same encounter for the same diagnostic reason. If, for example, the encounters are the same, but the radiologist performs a second set of views for a separate diagnostic reason than the first, you may code the column 2 code with modifier 59.

Side note: Rarely, if ever, will you find yourself in a scenario in which you should sum multiple chest X-rays into one combination code. The only way this would occur is if you encounter two separate chest X-ray reports from the same encounter for the same diagnostic reason. “Remember that, in cases of repeat procedures of the same chest X-ray code, you should use modifiers 76 [Repeat Procedure or service by Same Physician or other qualified health care professional] or 77 [Repeat Procedure by another physician or other qualified health care professional],” advises Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. Keep in mind, however, that these modifiers are only applicable if the chest X-ray codes have the same number of views (i.e. 71045, 71045-76).