Radiology Coding Alert

Avoid losing payment for pre-op chest x-rays by using correct diagnosis codes, staying in close contact with your states Medicare medical director, and ultimately billing the patient.

Radiology coding specialist Donna Richmond and her colleagues at Acadiana Computer Systems, a medical billing management company in Alexandria, LA, work closely with their states Medicare medical director so that even if Medicare denies payment for a pre-op chest x-ray, they are able to legitimately bill the patient.

Correct Diagnosis Codes Key

Denial of payment for preoperative chest x-rays, 71010 (radiologic examination, chest; single view, frontal) or 71020 (radiologic examination, chest; two views, frontal and lateral) is most frequently a result of unacceptable diagnosis (ICD-9) coding that doesnt justify the medical necessity for the examination. Since most surgeons refer nearly all patients for a chest x-ray prior to surgery, assuming it is a routine standard of care, radiology practices stand to lose significant amounts of revenue due to denials.

The American College of Radiology (ACR) has published a standard regarding pre-op chest x-rays: Preoperative radiographic evaluation is indicated if cardiac or respiratory symptoms are present or if there is a significant potential for thoracic pathology that may compromise the surgical result or lead to increased perioperative morbidity or mortality (Source: ACR Standard for the Performance of Pediatric and Adult Chest Radiography, effective Jan. 1, 1998). Medicare and other carriers in most states have adopted language similar to this.

If the surgeon has not documented clear medical necessity in the patients medical record, Radiology Coder often resort to assigning default V codes, such as V72.81 (preoperative cardiovascular examination) or V72.82 (preoperative respiratory examination). These often result in denials as wellwhich means lost revenue for the radiologist.

Richmond says this was the scenario her firm faced. Medicare in Louisiana at the time consistently denied these claims, noting that these pre-ops were not medically necessary since they were routine screening exams.

We then approached the medical director and pointed out that, since they considered pre-op chest x-rays routine exams, they should be denying them as not covered instead of not medically necessary.

Patient is Responsible for Payment

After reviewing this argument, Richmond says, the medical director concurred and began denying pre-op chest x-rays as PR-49 (patient responsible, service not covered). This allows her firm to bill the patient for the exam, even without an advance waiver. We have been able to recoup significant amounts of revenue this way, Richmond says.

Note: Because each state handles this issue differently, be sure to check with your local carrier. Most coding experts continue to advise that you obtain a patient waiver whenever possible to minimize collection problems after surgery.

The problem with this approach, she adds, is that often the patient is upset at being billed for the x-ray. We tell patients their doctor knew that routine pre-op chest x-rays, without documented medical necessity, are often not covered. Nonetheless, he or she ordered the exam.

Communicate With Medical Director

The moral of this story, Richmond says, is to stay in close contact with your states Medicare medical director.

We make a conscious effort to stay abreast of issues such as these and to communicate our views, she points out. This creates a relationship where we can work with the carrier. The original Medicare policy on pre-op chest x-rays was implemented in November 1996. Because of our professional relationship with the carrier, the change in how they denied the exams was in place by the following Apriland its been benefiting us since then.

Editors note: For a in-depth look at other issues surrounding coding for preoperative chest x-rays, see page 9 of the September 1999 Radiology Coding Alert.