Radiology Coding Alert

Better check physician’s intent and maintain documentation or risk denials.

Your physician may be doing intra-operative x-rays to facilitate surgical procedures, such as to help confirm instrumentation placement during the procedure, but you can’t always bill for these x-rays. To justify intra-operative x-ray services, you’ll need to have detailed and precise information for these x-rays in your records. Here is how you can avoid losing payment for any intra-operative x-rays.

Distinguish Review from Interpretation

The first thing you must know before reporting intra-operative x-rays is that surgeries performed in the hospital will only want you to report modifier 26 (Professional component ) — the hospital will report the technical component with modifier TC since the facility owns the equipment. Therefore, if your physician performed an intra-operative x-ray and didn’t write up a report, your practice cannot bill anything — only the hospital will collect for the technical component.” Make sure you are thoroughly documenting the reasons and findings for the intra-operative x-rays. For instance, when performing lumbar discectomy, must ascertain this is being performed on the correct level,” says Michele Midkiff, CPC-I, RCC, an interventional and neuro-interventional radiology coding consultant in Mountain View, CA.

This means that the x-ray interpretation and report is the linchpin to your reimbursement for the service, and if your documentation is missing that information, you could be left empty-handed.

Example: You may read that your physician performed an x-ray to help confirm alignment of the spine during a spine repair procedure. In this case, you should submit code 72100 (Radiologic examination, spine, lumbosacral; 2 or 3 views). However, you shall be able to earn for the x-ray only if you document that the x-ray was done to confirm surgical alignment. You append modifier 26 as your physician only interprets the report of the x-ray. The technical component of the x-ray is billed by the hospital.

In black and white: CMS confirms that you must maintain complete documentation of the x-ray findings. Chapter 13 of the Medicare Carriers Manual v(MCM) advises practices to distinguish between an actual x-ray “interpretation and report” and a simple “review” of the procedure, according to section 100.1.

The MCM states, “A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service…An interpretation and report should address the Three C’s: findings, relevant clinical issues and comparative data (when available).” According to MIdkiff, one always has to look from the perspective, “should our practice be audited, would the documentation stand alone?” Establish separate, clear paragraphs that stand out to an auditor.

1. Clinical findings – Briefly describe the findings.

2. Clinical issues – How this test is going to help manage the care clinically for the patient.

3. Comparative data – describe whether or how the condition is the same, better or worse.

For example, the MCM suggests that a notation in the medical records saying “fractured tibia” would not suffice as a separately payable interpretation and report of the procedure. Instead, the interpretation and report should note how many x-ray views the physician reviewed, the anatomic location of the injury, the reason the x-ray was medically necessary, and any applicable diagnoses.

You should keep your x-ray interpretation separate from the main body of the op report, separately sign it, and maintain copies for the medical records (digital or hard copy).

Example: If you read that your physician did radiological examination of ribs, you submit code 71100 (Radiologic examination, ribs, unilateral; 2 views). You could add a statement in your documentation like the following to support your interpretation: “The operating surgeon performed radiological supervision and interpretation of the ribs to guide fracture reduction and positioning of all hardware. The final images confirmed anatomic reduction of the fracture and appropriate positioning of all hardware. Permanent copies of representative images were produced and preserved as part of the medical record.”

Determine the Reason for the X-Ray

Your next step in ensuring payment for intra-operative x-rays is to confirm the physician’s intent for performing the service. For instance, suppose your physician does both the pre-reduction and post-reduction x-rays in a patient with fracture tibia. He dictates a separate note for each x-ray interpretation. In some cases, you’ll be able to report the x-rays, but in others you may not — it all comes down to intent. “It is imperative that the physician documents intent or reason for the exam, otherwise why would the carrier pay for what appears to be duplicate billing,” Midkiff says. “Describing the change in condition is key for reimbursement on the second exam.”

If the films require, and not just because you employ a “we interpret everything” policy, then you can report the studies based on the number of views you interpret. Films might require interpretation if the physician could not determine that the fracture was correctly aligned and needed a concomitant interpretation before finalizing the surgery.

In addition, if your physician does the pre-reduction x-rays to actually be able to diagnose the fracture, and subsequently interprets post-reduction films to confirm alignment, your insurer should reimburse both interpretations, as long as the physician documents the services appropriately. 

Avoid duplicate billing: Hospitals with radiologists on staff may have policies that all x-rays are read by their staff radiologists. Therefore, if those radiologists interpret the films and provide a record, the surgeon cannot charge for an interpretation.

In addition, your payers might have specific guidelines for reporting any intra-operative x-rays. Always check insurer policy, as well as the CCI edits, to ensure that you’re reporting these services accurately.