ED Coding and Reimbursement Alert

Most providers list dozens of diagnoses for chest exams

When your ED physician performs multiple exams, you must prove medical necessity with solid ICD-9 coding and choose a modifier to indicate physician involvement, or risk claim rejection.

We-ll make getting paid easy with this advice on coding single and multiple chest x-ray claims in the ED. Check LCDs for Covered X-Ray Diagnoses Patients who might require ED chest x-rays run the gamut, from accident victims to potential heart attack sufferers, says Stacy Gregory, RCC, CPC, from Tacoma, Wash.-based Gregory Medical Consulting Services. In addition to trauma patients, she lists the following conditions as possible precursors to a chest x-ray:

- chest signs and symptoms--chest pain, cough, congestion, difficulty breathing, or shortness of breath
- abnormal chest sounds (such as wheezing, rales, or crackles)
- fever/or cold and flu symptoms
- known or suspected myocardial infarction or cardiac arrest
- abdominal pain. Example: A patient with chest pain and labored breathing reports to the ED. The ED physician performs a single-view frontal chest x-ray. The results show the patient did not have a cardiac episode. On the claim, report the following:

- 71010 (Radiologic examination, chest; single view,  frontal) for the x-ray
- modifier 26 (Professional component) linked to 71010 to show that you are only billing for the interpretation of the x-ray
- 786.50 (Chest pain, unspecified) linked to 71010 to represent the patient's chest pain
- 786.09 (Dyspnea and respiratory abnormalities; other) linked to 71010 to represent the patient's breathing trouble.

Acceptable diagnoses: Your carrier has the final say on what codes prove medical necessity for chest x-rays, Gregory says. For example, Noridian Medicare in Washington state lists its acceptable ICD-9 codes at www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=23709&lcd_version=2&show=all.

Best bet: If you don't know what diagnoses your Medicare carrier covers for a chest x-ray, check out the local coverage determination (LCD). (For private payers, consult individual policies.) -There are more than 100 ICD-9 codes that support chest x-rays. It is one of the best-covered exams,- says Lori Hendrix, CPC,
CPC-H, coding consultant with Coding Strategies Inc. in Powder Springs, Ga.
                                                           
Use Modifiers on Multiple Chest X-Rays Sometimes, the ED physician will perform more than one chest x-ray on the same patient on the same date. This might be necessary in several situations, Gregory says. A second x-ray might be needed if:

- the physician requests additional views
- x-rays are performed before and after performing a procedure such as intubation or placement of a chest tube. Example: A patient presents to the ED with chest trauma after crashing his car into a boulder that fell onto the road. The physician performs an initial single-view chest x-ray and identifies a traumatic pneumothorax.

The physician immediately places a chest tube to allow the lungs to re-expand. After the insertion, the ED physician takes a second single-view [...]