Radiology Coding Alert

Document the medical necessity and append Modifier 76 when possible.

You may be losing out on payment if you are not billing for post-procedure x-rays. X-ray examinations, though part of follow-up, aren’t covered in procedure packages. Here is how you can beat a common myth for x-rays done in global periods.

Myth:  X-rays that you shoot or interpret during the global period are not billable to Medicare because payers include these charges in the surgical package.

Reality: Practices that don’t bill their x-ray charges are throwing away thousands of dollars in rightful reimbursement. “X-rays are not included in the global package and may be separately reported when there is medical necessity and a signed written report,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA.

Scenario: An established patient, who reported with pain, swelling, and tenderness of the left wrist and forearm, was diagnosed with a buckle fracture of the wrist. The attending physician stabilized the fracture with a splint before sending the patient home. The patient returns four weeks later and the physician advises two follow-up x-rays of the patient’s forearm. The patient then presents to the radiology department for the x-rays.

Bill Those Follow-Up X-Rays

The challenge: You should report fracture care (25600, Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) and any x-rays performed for the initial visit. But can you report the follow-up x-rays?

The solution: Go ahead and report those films. If your practice performed and interpreted the x-rays, report 73090 (Radiologic examination; forearm, two views).

X-rays determine the patient’s condition and the course of care, so they are not included in global packages. You can also report any follow-up x-rays separately. If you don’t separately report the x-rays, you risk losing significant reimbursement.

Because Medicare payers will reimburse about $28 each time you report 73090, failing to report the x-rays could be an expensive mistake over the course of a year.

When a fracture care code is selected, this only includes the initial casting and all follow-up visits within the 90 day global period. All x-rays, subsequent castings and supplies are not included in the fracture care code. These services and supplies are not considered as edits or mutually exclusive codes by the Correct Coding Initiative (CCI). “In fracture care, x-rays are used to diagnose and identify the type of fracture and determine the course of treatment for the patient, therefore they are considered diagnostic and are separately billable,” Hembree says. 

The utility of x-rays extends beyond fracture care. “X-rays are a great tool for monitoring a patient’s condition,” Hembree says. “They may be taken after placement of a pacemaker or placement of another internal device such as a joint prosthesis. The key is to make sure they meet the criteria of being diagnostic and that you have medical necessity.”

Billing x-rays outside of the global period doesn’t apply only to fracture care claims. In fact, diagnostic services are not considered part of the global package in general, and may be billed separately. “The global period rules are the same across the board for all specialties,” Hembree says. “According to Medicare Claims Processing Manual Chapter 12, diagnostic tests and procedures, including diagnostic radiological procedures are not included in the Global Surgical Package,” Hembree says. 

Per CCI, the only x-rays that are included in a procedure are those that are intra-operative, such as checking the placement if a manipulation was performed before the cast was placed. “Intra-operative services that are normally a usual and necessary part of a surgical procedure are considered to be components of the surgical procedure and, therefore, included in the global surgical fee. Checking the placement if a manipulation was performed before the cast was placed or intra-operative fluoroscopy during a spinal surgery is typically considered to be an integral part of the procedure and is not separately reportable,” Hembree says.

X-rays that are taken pre- and post-reduction , i.e. before manipulation and after manipulation and casting have taken place, are reported using the correct CPT® code from the radiology section and appending a modifier 76 (Repeat procedure or service by same physician or other qualified healthcare professional) to the post-reduction x-ray.