Radiology Coding Alert

Question: Our physician did an X-ray examination in a baby aged 4 months. The procedure notes only mention X-ray conducted. The specific region examined is not mentioned. Can you provide guidance on how to report this incomplete procedure?

Ohio Subscriber

Answer: You are not correct in interpreting the X-ray examination as incomplete. It is possible that your physician did a whole body radiological survey. Look in the procedure note and check for results reported. If your physician did an osseous survey, there would be results of imaging impressions for both the axial and appendicular skeleton. If you confirm the radiological survey, you should submit code 77076 (Radiologic examination, osseous survey, infant). This code typically applies to babies of age one year or less.

Why osseous survey? Your physician may do an osseous survey in an infant with skeletal dysplasias, metabolic disorders (rickets and rickets-like disorders), and disseminated neoplastic conditions. Such surveys are also done in cases of child abuse and violence.