Radiology Coding Alert

CMS' change in policy on preoperative chest x-rays has not been as absolute as radiologists hoped, in part because payers have implemented the policy inconsistently. The new policy has caused radiology coders to be more diligent in assigning appropriate diagnosis codes before submitting claims, thereby increasing their payment opportunities, says Michelle Juette,CPC, RCC, business services manager for Yakima Valley Radiology in Yakima, Wash. Traditionally, Medicare and most private payers consistently denied preoperative x-rays and refused to allow the patient to be billed unless stringent guidelines for medical necessity and advance beneficiary notices (ABN) were documented. As a result, many radiologists lost lots of money on the common studies. Payers Can't Automatically Deny V Codes Preoperative chest x-rays (e.g., 71010, Radiologic examination, chest; single view, frontal; or CPT 71020 two views, frontal and lateral) are often ordered by surgeons wanting to ensure their patients can withstand surgery, notes Juette, who says practices can easily lose tens of thousands of dollars a year on pre-op x-rays. Pre-op chest x-rays are particularly common when the elderly and young children have surgery, and when patients have medical conditions that may complicate the procedures. For example, a 6-year-old diagnosed with caries (521.0x, Dental caries) may require dental surgery to extract the diseased tooth. Anesthesia is required because of the patient's age, which might necessitate a preoperative evaluation when certain clinical conditions are present. The diagnosis code radiology practices use most frequently for preoperative chest radiography is ICD-9 V72.83 (Other specified preoperative examination), which is assigned when a wide range of surgical procedures are planned. Other codes include V72.81 (Pre-operative cardiovascular examination), which is used prior to cardiovascular surgery or when the patient has a pre-existing cardiac condition; or V72.82 (Pre-operative respiratory examination), which is reported before respiratory surgery or when a pre-existing respiratory condition exists. These latter two codes describe a comprehensive physical examination, and some coding experts recommend they not be used simply for preoperative x-rays. In the past, most local Medicare carriers adopted a blanket policy and automatically denied routine preoperative tests conducted in the absence of a diagnosed disease related to the test. They viewed the x-rays as screening, rather than medically necessary evaluations. The 2001 CMS directive eliminated this unilateral viewpoint and forced local carriers to accept the V codes supporting medical necessity when appropriate. For example, conditions supporting medical necessity of preoperative chest x-rays include history of cardiovascular disease (e.g., 412, Old myocardial infarction), respiratory diseases like asthma (e.g., category 493), or a recent episode of pneumonia (e.g., category 480-486). The specific circumstances allowing preoperative evaluations will be determined by the local carriers and communicated in local medical review policies (LMRPs). Coders Must Become Detectives While this [...]