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Radiology Coding Alert

Resolve Five Perplexing X-Ray Studies

Published on Mon Oct 01, 2001

A number of x-ray studies sometimes furrow a coder's brow -- especially when two or more body parts are imaged during the same session. The following are five common studies that cause coding problems:
 
1. Unilateral Hip and Bilateral Hips
2. X-rays of Ribs and Chest
3. Joint Survey
4. X-rays of Hands, Fingers
5. Knees
 
1. Unilateral Hip and Bilateral Hips. Language in code descriptions for radiological examinations of the hips sometimes confuses coders.
 
CPT provides two clear-cut codes for unilateral studies, says Michelle Juette, CPC, RCC, business services manager for Yakima Valley Radiology in Yakima, Wash.: 73500 (radiologic examination, hip, unilateral; one view) and 73510 (... complete, minimum of two views). Likewise, coding a bilateral study involving only one view of each hip is equally uncomplicated. "The coder would report 73500 twice with the bilateral modifier -- either modifier -50 (bilateral procedure) or the -RT/-LT indicator, depending on payer guidelines," Juette says.
 
Less straightforward, however, is the code for another bilateral exam, CPT 73520 (radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis). "The reference to an AP view of the pelvis raises the question of how to code bilateral x-rays with multiple views," she points out. In many instances, coders assume that the original physician's order or the radiology report must indicate that a separate AP pelvis was obtained and documented, in addition to two or more views of both hips.
 
But this isn't the case. When x-raying hips, technicians routinely obtain an AP view of the pelvis along with views of the hip (i.e., lateral, side). The language in 73520 reflects this common practice, but performing a discrete AP pelvis when bilateral views of the hips are obtained is not required. Therefore, 73520 is appropriately reported for any bilateral hip study with two or more views.
 
Because 73520 has caused problems, clarification of the code through the CPT channels has been requested. Modifications for CPT 2002 are already nearing completion, and any change in 73520 is not expected until 2003.
 
2. X-rays of Ribs and Chest. Much like hips and pelvis x-rays, coders are confused occasionally with ribs and chest studies because they encompass the same portion of the body. "They are distinct, however," explains Linda Lane, CPC, director of patient accounts for University Radiology Associates of Cincinnati Inc., in Ohio. "Most chest x-rays will be studies of the soft tissues within the rib cage, while x-rays of the ribs focus on the bony structures."  The majority of rib studies will be ordered due to chest pain that might result from trauma (e.g., a fracture sustained in a car accident [807.0, fracture of ribs, closed]). Chest x-rays are ordered when conditions like pneumonia (480.x, viral pneumonia) or a neoplasm (162.3, malignant neoplasm of trachea, bronchus and lung; upper lobe, bronchus or lung) are suspected.
 
Codes 71010-71035 describe chest x-rays including single-view, two-view and complete studies, as well as a number of special studies. Similarly, codes 71100-71111 are assigned for ribs x-rays. "Coders should be aware that two of the ribs codes include a single view of the chest, however," Juette cautions. These include 71101 (radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views) and 71111 (radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of four views).
 
These codes represent explicit pairings of a single chest and multiple ribs studies, she adds. Other combinations would be reported with codes that represent the specific number of views for each body part. For instance, if a two-view chest and a right-or-left side rib x-ray were ordered, coders would assign 71020 (radiological examination, chest, two views, frontal and lateral) and 71100 (radiological examination, ribs, unilateral; two views).
 
Lane says coders should be aware that the Correct Coding Initiative (CCI) has implemented an edit indicating that 71010 (radiologic examination, chest; single view, frontal) should not be reported with 71111. These two codes are bundled and may be separately reported only with a modifier explaining why both were assigned. For instance, an x-ray of the ribs with a PA chest may be done during an initial emergency department encounter, indicating that a patient suffered a rib fracture causing a pneumothorax (860.0, traumatic pneumothorax and hemothorax; pneumothorax without mention of open wound into thorax). Several hours later, a single-view chest x-ray may be repeated to determine the status of the pneumothorax. In this instance, both 71111 and 71010 may be reported, with modifier -59 (distinct procedural service) added to the chest code.
 
3. Joint Survey. Calling it "nefarious" for tripping up radiology coders, Juette says 76066 (joint survey, single view, one or more joints [specify]) should rarely be assigned. "The problem is that the code definition clearly states a single view, which is rarely what is ordered."
 
Typically, this code is used when a single PA view of both hands or a single AP view of both feet is done in a rheumatoid arthritis survey (714.0, rheumatoid arthritis). This code may also be used in pediatric imaging for certain suspected conditions such as juvenile rheumatoid arthritis or to see if a more complete study of a specific area is necessary.
 
More commonly, a physician will order a two- or three-view study when patients complain of problems with a particular joint, she says. In this case, the radiologist will obtain the images ordered, and a specific imaging code for the joint being studied is assigned (e.g., 73070, radiologic examination, elbow; two views, or 73071, ... complete, minimum of three views).
 
4. X-rays of Hands, Fingers. Radiology experts note coding hands and fingers x-rays can be perplexing because the codes for studies of the hand say nothing about the fingers. This exclusion indicates that a hand code (73120, radiologic examination, hand; two views, and 73130, ... minimum of three views) and the fingers code (73140, radiologic examination, finger[s], minimum of two view) may be reported when x-rays of both are obtained.
 
If fingers on both hands, or both hands themselves, are x-rayed, the codes would be reported twice, appended with the appropriate bilateral modifier (i.e., modifier -50 or the -RT/-LT designation).
 
Note: Appendix A (modifiers) of the CPT manual has a section relating to Level II HCPCS modifiers. Among these are modifiers that identify fingers on each hand. These would not be used when reporting professional services, but apply only to hospital-based charges.
 
5. Knees. X-ray studies of the knees are often performed in a prone or supine position, where the patient is lying or sitting on the table. Codes for images obtained in this manner are relatively straightforward: 73560 (radiologic examination, knee; one or two views), 73562 (... three views) and 73564 (... four or more views). However, coders may be confused when one of these studies is performed with an x-ray done while the patient is upright (73565, ... both knees, standing anteroposterior).
 
Coding experts note that when obtained during the same session as other views, the standing views would not be reported as a separate service. Instead, they would be included in the total number of views obtained during the session. For instance, if AP views of both knees are obtained in the erect position and lateral views are obtained in the supine position, coders would assign the code for two views of each knee (two units of 73560 with the bilateral modifier). It would be incorrect to report a single view of the right knee, a single view of the left knee (again, two units of 73560 with the bilateral modifier) and 73565. Code 73656 should be used when only an AP upright view of both knees is obtained.

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