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.

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).

While this directive appeared to clear a path for greater reimbursement, that hasn't been the case, says Patti Chapman, Medicare coordinator for Radiology Associates in Monroe, La.: "What it has done, instead, is encourage coders to do more work up front. It is worthwhile to find out as much information as possible about the patient's condition and reason for the surgery. That gives us the data we might need to report an acceptable diagnosis code." In other words, the claim submitted must contain the pertinent information to support the examination's necessity, based on Medicare regulations. Obviously it is best to collect this pertinent information in advance. If this is not possible, the coding and billing staff must be diligent in collecting such information after the fact to support successful collections.

Juette agrees: "It has turned coders into detectives. We are motivated to do the legwork necessary to find out if there is an underlying medical condition that supports the chest x-ray." In the case of the child with dental caries, it is unlikely that any insurer would pay for preoperative chest x-rays for oral surgery. However, the child may have a chronic health problem like a clinically significant ventricular septal defect or VSD (745.4), which would indicate that the claim should be reimbursed.

When reporting a preoperative chest x-ray, the V code appears as the primary diagnosis code on claim forms because it indicates the reason for the encounter, Chapman says. Any conditions requiring the x-ray are reported in the second position and the reason for surgery in the third. If there are any significant findings of the chest x-ray, such as infiltrates (793.1), these conditions are sequenced last.

"The code in the second position is key," Juette says. "If it complies with the list of permissible codes issued by the carrier, the x-ray will be paid."

To increase the likelihood of payment, Juette recommends three strategies:

Communicate with the referring physician. "The orders for the x-ray very seldom give the radiologist enough information about the patient," she says. "But, we can certainly contact the ordering physician and ask about any conditions or history that supports the x-ray. If this conversation is documented, it can be reported with the claim."

Code any presenting signs or symptoms. On occasion, she notes, the patient may experience legitimate symptoms tightness in the chest (786.59), for instance, or a cough (786.2) that would be evaluated before surgery. If this is the case, record corresponding codes in the claim's second position.

Document and report findings. Most payers allow, if not encourage, radiology practices to report the findings of diagnostic exams they conduct. "In the past, we only documented signs and symptoms," Juette says. "But now we can include the actual findings of the x-ray. This opens up a lot of diagnostic possibilities, too."

For instance, images obtained on an otherwise asymptomatic patient may uncover evidence of a previously undiagnosed old myocardial infarction (412). The radiology coder may include this on the claim's second line, thereby providing the documentation necessary to make the exam payable.

The propensity for carriers to deny preoperative x-ray claims has forced radiology practices to turn to the patients for payment, Chapman says. Although many patients resent being billed, it is an avenue many radiologists explore.

The reason a local Medicare carrier provides for denial drives the approach a practice can use with patients. If the claim is denied as a "noncovered service" and comes back with the PR-49 (patient responsible) indicator, the patient can be billed even if no ABN is on file. However, if the claim is denied as "not medically necessary," the practice can charge the patient only if an ABN has been signed.

Each carrier may handle these denials differently, and coders must check with the local medical director. In some cases, discussions with local carriers have resulted in an agreement to deny preoperative x-ray claims as "not covered" to ease the practice's collection burden. However, to minimize payment problems, most coding experts advise practices to obtain a patient waiver whenever possible.