ED Coding and Reimbursement Alert

Question: The ED performed a four-view x-ray of a patient's left knee, including lateral and sunrise views in both standing and non-standing positions. The ED circled 73564 (Radiologic examination, knee; complete, 4 or more views), but the documentation for the claim simply says, "Standing/non-standing left knee x-ray." We are the billing service and we aren't sure if we can bill this claim using this documentation. Can you advise?

Codify Subscriber

Answer: You are correct in suggesting that this claim should not be billed with this documentation, because this note is not thorough enough to support billing a four-view x-ray. Even though the doctor may have circled 73564 on the claim, the documentation does not indicate that four views were taken. If a payer audited this note, you would likely be downcoded to 73560 (Radiologic examination, knee; 1 or 2 views), giving you credit for one view of the knee in standing position and one view in non-standing. Since 73560 pays about $31 and 73564 reimburses about $40, you'd have to refund $9.00 to the payer for this claim.

Remind your physicians of the importance of thorough documentation regarding the number of views so you can ensure that this mistake doesn't happen in the future.