Radiology Coding Alert

Question: How do you report an intra-operative X-ray that our physician reviewed during a spine surgery?

New York Subscriber

Answer: You 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 (Professional component) as your physician only interprets the report of the X-ray. The technical component of the X-ray is billed by the hospital.

CMS confirms that you must maintain complete documentation of the X-ray findings. Chapter 13 of the Medicare Carriers Manual (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).”

Establish separate, clear paragraphs that stand out to an auditor, should your practice be audited. Make sure you document:

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 spine” 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).