Orthopedic Coding Alert

Views and modifiers in diagnostic X-rays can influence your payments

You code lots of diagnostic X-rays, but are you sure you're appropriately reporting these? The key to accuracy in X-ray coding is the number of views, not the number of films and appending the correct modifiers for bilateral views, distinct services, and the repeat procedures.

Count the Views, Identify Location

You may fall prey to an audit if you are poor at reporting the views in X-rays. Scan the procedure note for the number of views required to appropriately visualize the anatomy of the injured area. Doing so will influence your reimbursement: You get $34.31 if you report code 73080 (Radiologic examination, elbow; complete, minimum of 3 views) and $28.54 if you report code 73070 (Radiologic examination, elbow; 2 views).

Where the number of views is not mentioned, you may report the code that mentions the minimum number of views. "Documenting an X-ray interpretation is one area where orthopedists are often deficient. Simply stating that the X-rays of the elbow were taken and are negative for fracture, is not adequate documentation. The imaging interpretation should make it clear that the films were taken in the orthopedist's office and that the surgeon is not reviewing films that were taken elsewhere and were already read by another physician, as reviewing films is inclusive to the E&M service. Other necessary components of the X-ray interpretation are: indication(s) for examination, anatomic site studies, views taken, description of findings, impression or conclusion," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

Example: You will most commonly see anteroposterior (AP) and lateral views of the elbow as these show the joint integrity and help to identify fractures and loose bodies. In a patient who had a fall on an outstretched hand and developed swelling in the elbow, your orthopedist may advise AP and lateral view of the elbow to confirm a nondisplaced medial epicondylar fracture. If the note further states that patient was given a posterior arm splint with the elbow immobilized at degrees to the forearm in neutral rotation, you would code 73070 in addition to 24560 (Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation).

Carefully read through the note to avoid missing payments on the X-rays. More than one view is usually recommnended for all bone and joint radiographs. "Most orthopedists like to see radiographs of any joint taken in two planes 90 degrees opposed to one another, and quite frequently, as in the shoulder or knee, three views are obtained, and occasionally even more," says Dr. Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

Example: Your orthopedist may like to see an oblique view of the elbow in addition to the AP and lateral views if a fracture of the lateral condyle is suspected to ensure that no fine or faint fracture line is overlooked. In this situation, you report code 73080 in addition to 24576 (Closed treatment of humeral condylar fracture, medial or lateral; without manipulation) as manipulation is not done for very fine fractures.

Similarly, the traditional AP and lateral views done in elbow trauma may not be enough in the capitellum fracture. The distal end of the humerus in the AP view can obscure the fractured fragment of the capitellum and the lateral views may fail to reveal an undisplaced fragment. In this situation, the orthopedist may request for accessory views like the radial head-capitellum view to avoid overlaps between the humeroradial and humeroulnar joints as it clearly shows the radial head, capitellum, and coronoid process when the radiographic beam is angled 45 degrees towards the radial head.

Avoid Overlap In Codes For Number Of Views

Be careful in avoiding overlap in codes as it may compromise your payment. For example, if the orthopedist requests three views of a patient's wrist, plus posteroanterior and ulnar deviation wrist views taken at the same session, you only report code 73110 (Radiologic examination, wrist; complete, minimum of three views). Along with this, you do not report code 73100 (Radiologic examination, wrist; 2 views). Here 73110 clearly specifies 'minimum of three views,' and is hence also inclusive of the posteroanterior and ulnar deviation views.

Beware: You do not separately report 73110 for three views and 73100 for two views. If you report the two together, you will be reimbursed for only 73110 because Correct Coding Initiative (CCI) bundles 73100 into 73110.

Also make sure you do not miss reporting the stress views. These are special views taken after the physician subjects the anatomical area to stress and obtains another view to understand the changes, if any, induced by stress. "These are rarely done anymore," says Dr. Mallon.

Example: If the orthopedist does the standard anteroposterior/lateral and scaphoid views, as well as ulnar deviated, ulnar oblique, radial deviated and radial oblique views in a patient and also interprets the stress view of the wrist, you report code 73100 for the anteroposterior, lateral, scaphoid, ulnar deviated, ulnar oblique, radial deviated and radial oblique views and also code 77071 (Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated) for the stress view.

Don't Be Finicky On Films

You are definitely mistaken if you think that views and films are alike. You may even find two views on a common film, if the orthopedic office is still using film and computed or digital radiography. In such instances, you code for the two views.