Radiology Coding Alert

Question: According to the February 2004 Radiology Coding Alert article "NCCI Edits 10.0 Targets the New Central Venous Access Codes," Medicare will now bundle post-line placement chest x-rays into central venous catheterizations (CVC). But what if we perform a chest x-ray the next day to confirm placement? Will the insurer bundle that x-ray into the CVC charge as well?

Texas Subscriber

Answer: You present a sticky situation because the National Correct Coding Initiative (NCCI) initiated the bundling edit to capture services that insurers consider "quality assurance" or "integral to" the original procedure, which radiologists normally perform on the same date of service. Because you performed the x-ray for such quality assurance purposes (to double-check the CVC placement), insurers would probably consider the x-ray integral to the CVC placement as well.
 
If, however, your practice performed the chest radiograph for a specific and separate clinical question, the answer would be different.
 
For example, if you perform a routine radiograph to document the final catheter position, insurers will bundle that payment into the line placement radiological supervision and interpretation (RS&I) code.
 
But, if your practice performs serial chest radiographs to manage a condition such as a pneumothorax (even if the pneumothorax is a complication of the original line placement), insurers consider the procedures separate and distinct services and should reimburse you for both procedures. Remember that your clinical documentation must support the medical necessity of the two distinct and separate services.
 
Therefore, if your radiologist performed the second-day chest x-ray to follow up on a problem that he detected during the initial procedure, most insurers would not consider the x-ray routine quality assurance and likely would not include the x-ray in the CVC bundling rules.
 
On the other hand, payers that follow NCCI guidelines will not bundle your chest x-ray into your CVC placement because procedures that you perform on subsequent days are not subject to NCCI bundling edits.
 
But if your insurer analyzes code utilization (which most payers do on a random basis), your coding pattern may flag an audit. The payer may want to determine whether the chest x-ray was associated with the line placement, and if so, it might wonder whether you performed the x-ray on a different date simply so you could avoid the edit.
 
Your best bet is to contact your local carrier for specific billing guidance in this situation.