Radiology Coding Alert

Question: In a patient who incurred a leg injury following a car accident, the surgeon ordered an x-ray of the legs. X-rays were requested for both the affected leg as well as the normal leg for comparison.  The insurer denied the x-ray claim for the unaffected leg and only paid us for a unilateral x-ray. What could be the reason for this denial? What do you suggest as next steps for us?

Alabama Subscriber

Answer: Comparison views for legs are usually obtained in children. Your payers may reimburse this. However, in adult patients, you cannot always submit claims for comparison views, as there is no medical necessity, i.e., no diagnosed medical condition. You should confirm the nature of injury with the surgeon and ensure documentation. If your physician obtains comparison images of the opposite leg to determine leg length (in event of a fracture), you may be reimbursed for this. However, in the scenario described by you, this is unlikely. You may not stand a chance for appeal in this case. 

Comparison views in children: In children, physicians sometimes order comparison views because they suspect growth-plate injuries. Usually, comparing the left side to the right can confirm an injury to the growth plate. 

Comparison views in adult patients: Generally in adults, the insurers consider x-rays of the non-injured side as a screening x-ray. This is because an appropriate diagnosis to justify medical necessity on the healthy leg is usually missing.

Keep documentation: Your physician needs to document clearly the medical necessity why the comparison view is needed. You should then submit the claims with the LT (Left side) and RT (Right side) modifiers, and include a letter in which the physician describes the medical necessity for the unaffected side. 

How to code? You can submit the x-ray code V72.5 (Radiological examination, not elsewhere classified). When ICD-10 is implemented and your diagnosis system changes, you will report Z01.89 (Encounter for other specified special examinations).