Wiki Billing a bilateral knee xray with a unilateral knee xray

[alyssa1990]

Ex:
When a provider orders a bilateral xray of the knees AND 3 additional views of the right knee, per CCI guidelines we are not allowed to bill the bilateral xray with a unilateral xray code.
What we have been doing is removing the charge for the bilateral xray (CPT 73565) and instead using the CPT codes for 1-2 view of the LT knee (73560) and 4+ views of the RT knee (73564), with an XU or XS modifier. Is this the correct way to bill it?

Otherwise we were thinking we could remove the charge for the unilateral xray(s) and ONLY bill the bilateral xray code. If we did it that way, we would have different charges built into our chargemaster for the same bilateral knee CPT code (73565), that way a total of 2 views would be cheaper than a total of 5 views...if that makes sense. For example, there would be different labels (1-2 views, 3 views, 4+ views) that would all be attached to the bilateral CPT code 73565, but they would all have different dollar amounts associated with the number of total views of both knees combined. I did bring up the question if the insurance companies would have their agreed upon dollar amount for the bilateral CPT so it wouldn't matter if we changed the price or not, but they did not think that would be an issue. Does anyone bill it this way?

Someone also asked about if there was any correct way to bill it with modifier 50, but I don't believe there is. Any advice on this situation is greatly appreciated!
Thanks

 

[thomas7331]

Radiology isn't really my specialty, but I don't understand why you're saying CCI doesn't allow you to bill the bilateral with the unilateral code. I would think you should be billing what is actually done here: 73565 for the bilateral film and 73562 for the 3 unilateral view. 73562 is allowed with a modifier per the CCI tables, which would be supported if these are separate studies, so a 73562-59 or 73562-XU should be appropriate.

 

[alyssa1990]

Thanks for the response; However, per Vitalware, which is the website we use for CCI edits, even if 73562 has the modifier it says "73565 Cannot be billed with 73562; modifier not allowed". See attachment for a screenshot of the website/edit.

 

[thomas7331]

Are you billing on the facility side? I see that's a new edit added 10/1/20 but it's only on the facility tables, not on the physician tables. I don't see any guidance in the new NCCI manual to explain why they added this or what the coding expectation, so I almost wonder if it's an error. You might have better luck looking on one of the facility coding organization sites.

On the facility side, I do see that all of these codes now classify to the same APC 5521, so I don't think it's going to change any of your payments one way or the other regardless of how you do it - perhaps that has something to do with the rationale for this edit. If your MAC allows it, you might consider just putting it through and letting the code deny as I don't think it's going to change the payment in the end.

Sorry not to be able to help more. Perhaps someone with more facility radiology background may be able to answer how they're handling this.

 

[TPeniston61]

CPT Code 73565 is not really a bilateral knee x-ray code. It is very specific: it is an x-ray of both knees, standing. If you are doing separate x-rays for both RT and LT sides, bill with 73560-RT and 73560-LT. You can't bill the 73562 with 73565. At our practice, we often bill 73565, 73565-RT and 73560-LT together, usually for initial visits. They are always paid.