Radiology Coding Alert

Palmetto providers: Your list of diagnoses supporting medical necessity just grew.

A chest X-ray's professional fee is only $10 or so. Multiply that $10 by the number of services you perform, however, and you'll quickly see how getting these claims right is important to your practice's financial health.

In fact, 71010 (Radiologic examination, chest; single view, frontal) and 71020 (Radiologic examination, chest, 2 views, frontal and lateral) rank second and third on the list of the top 10 codes radiologists reported to the CMS database in 2009. That's according to files recently posted by Frank Cohen, MPA, principal and Senior Analyst for The Frank Cohen Group (www.FrankCohen.com). (To see what other codes are on the list, see the Table on page 43.)

Below, you'll find 71010 and 71020 essentials, including example services, typical supporting diagnosis codes, and advice on avoiding the most common causes of audit-related denials.

Boost Your X-Ray Skills by Understanding Views

Each 71010 or 71020 service may require just a few minutes of the radiologist's time. Typically, she makes a quick review of the patient's history, interprets the exam performed by the technician, dictates and signs the report, and shares the results with the ordering physician.

The key element distinguishing 71010 from 71020 is that the first represents a single "frontal" view and the second represents two views, "frontal and lateral."

71010: The documentation for a 71010 service may refer to an "AP view," says Alice Wonderchek, CPC, billing and coding specialist with Ohio-based Radisphere National Radiology Group. AP stands for anterior-posterior, meaning the X-rays pass from the anterior (front) to the posterior (back) of the patient.

You also may see reference to a "PA view" (posterior-anterior), in which the X-rays pass from the back to the front of the patient. The AP view can be more difficult to interpret than a PA view because of quality issues and the way the heart appears enlarged on an AP view. As a result, providers often prefer the PA view over the AP view.

You typically will see an AP view when the patient cannot stand for the imaging service. As a result, another term you'll often see connected to 71010 services is "portable," meaning the tech takes the X-ray using a portable machine. You may see this particularly for services performed at bedside for inpatients, Wonderchek says.

Example: A post-op patient who has just been moved to recovery exhibits decreased breath sounds and low oxygen levels. The physician orders a portable AP chest X-ray to be performed at the patient's bedside. You should report 71010 for the radiologist's services. Remember to append modifier 26 (Professional component) when you report only the professional component of the X-ray service.

71020: You may see a 71020 service referred to as a "PA & Lat," Wonderchek says. The abbreviation refers to the PA (posterior-anterior) view and the Lat (lateral) view. Lateral means "side." Generally, the tech will take a left lateral X-ray, meaning the patient's left side is closer to the film than the right side is. But the ordering physician may ask for a right lateral X-ray instead.

Example: A patient with a history of lung cancer presents complaining of fever and shortness of breath. Her oncologist orders PA and lateral X-ray imaging. The interpreting radiologist should report 71020. Again, append modifier 26 if you're reporting only the professional component.

Whittle Down the List of Likely Diagnoses

Physicians order chest X-rays for a wide variety of reasons, especially in theemergency room setting. The potential exam findings also add up to a long list. Consequently, there are many ICD-9 codes that may apply to a chest X-ray claim.

Some of the diagnosis codes that Wonderchek links to chest X-rays on a daily basis include:

• 401.9, Unspecified essential hypertension
• 486, Pneumonia organism unspecified
• 511.9, Unspecified pleural effusion
• 518.0, Pulmonary collapse
• 793.1, Nonspecific (abnormal) findings on radiological and other examination of lung field
• 786.05, Shortness of breath
• 786.09, Respiratory abnormality other
• 786.3x, Hemoptysis
• 786.50, Unspecified chest pain
• V72.83, Other specified pre-operative examination.

Smart move: Check your payer's local coverage determination (LCD) to see which codes it says support medical necessity. There's a good chance you'll find a long list.

You also should check for updates to your policies. For example, effective May 26, 2011, Palmetto GBA added V10.3 (Personal history of malignant neoplasm; breast) to the list of codes supporting medical necessity in its LCD for "Radiologic Examination, Chest" (L28298).

Keep in mind, you should report only those diagnosis codes supported by the documentation. You should not choose an ICD-9 code simply because you know it will get the claim paid.

Learn the Lessons of Palmetto Review

Perhaps because chest X-rays are so common, documentation for these services often isn't as meticulous as it should be. That means the documentation may not match up to payers' standards.

Case in point: Palmetto GBA recently completed a review of 71010 and 71020 claims for November 2010 through January 2011 in Southern California. The Jurisdiction 1 Part B MAC reviewed 3,233 claims and denied 1,610 -- a 49 percent denial rate. Here is a look at the most common problems and the solutions Palmetto suggests.

Problem 1: A whopping 42 percent of the denials were due to the service lacking the necessary provider's order.

Solution 1: Palmetto suggests that providers be sure to include the order when they're asked to submit documentation to the payer. In addition, you need to be sure the order meets signature requirements.

Problem 2: More than one-third of the denials were a result of the provider not submitting the requested documentation.

Solution 2: If your practice receives a request from your payer for documentation, follow the directions so that your claims are not denied simply because you failed to respond.

Problem 3: Lack of a radiology report caused 11 percent of the denials.

Solution 3: Avoiding this problem may be as simple as doublechecking the documentation before you send it to the payer to be sure you've included the necessary signed report.

Problem 4: Issues with patient identification or the date of service caused 3 percent of the denials.

Solution 4: Check that the documentation legibly and completely identifies the patient and date of service in the appropriate fields.

You'll find Palmetto's announcement, "Completion of Prepayment Service Specific Complex Review for CPT® Codes 71010 and 71020, Chest X-ray Services, Southern California" at www.palmettogba.com/palmetto/providers.nsf/ls/J1B~8GQRTD3358?opendocument&utm_source=J1BL&utm_campaign=J1BLs.