Orthopedic Coding Alert

You can only report modifier 26 for these—if anything at all.

If you perform x-rays during surgery, your op reports had better include an interpretation report, or you might be billing your insurer for services that you aren’t entitled to collect.

Orthopedists often order x-rays while in the operating room—for example, to confirm instrumentation placement—but the x-ray interpretations aren’t always billable. To determine whether your interpretation should be included in the surgery, always look for the report, and review the physician’s intent.

Distinguish Review From Interpretation

The first thing you must know before reporting intraoperative x-rays is that surgeries performed in the hospital will only warrant the surgeon reporting modifier 26 (Professional component )—the hospital will report the technical component with modifier TC since the facility owns the equipment. Therefore, if you perform an intraoperative x-ray and don’t write up a report, your practice cannot bill anything—only the hospital will collect for the technical component.

This means that the x-ray interpretation and report is the linchpin to your reimbursement for the service, and if your op report is missing that information, you could be left empty-handed.

In black and white: CMS confirms that you must maintain complete documentation of the x-ray findings. Chapter 13 of the Medicare Carriers Manual (MCM) advises practices to distinguish between an actual x-ray “interpretation and report” and a simple “review” of the procedure, according to section 100.1.

The MCM states, “A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service…An interpretation and report should address the findings, relevant clinical issues and comparative data (when available).”

For example, the MCM suggests that a notation in the medical records saying “fractured tibia” would not suffice as a separately payable interpretation and report of the procedure. Instead, the interpretation and report should note how many x-ray views the physician reviewed, the anatomic location of the injury, the reason the x-ray was medically necessary, and any applicable diagnoses.

You should keep your x-ray interpretation separate from the main body of the op report, separately sign it and maintain copies for the medical records (digital or hard copy).

Example: You could add a statement in your documentation like the following to support your interpretation: “The operating surgeon performed radiological supervision and interpretation of the ribs to guide fracture reduction and positioning of all hardware.  The final images confirmed anatomic reduction of the fracture and appropriate positioning of all hardware.  Permanent copies of representative images were produced and preserved as part of the medical record.”

What Is the Physician’s Intent?

Your next step in ensuring payment for intraoperative x-rays is to confirm the physician’s intent for performing the service. For instance, suppose your orthopedic surgeon orders pre-reduction x-rays and interprets the films. He then reduces the fracture and orders post-reduction x-rays. He dictates a separate note for each x-ray interpretation. In some cases, you’ll be able to report the x-rays, but in others you may not—it all comes down to intent.

If you order the films to document the “before and after” condition of the patient’s fracture, the films are potentially part of the surgical procedure, because the intent is to simply document the surgical service, in which case you should not report your interpretations separately.

If, however, the films require interpretation and not just because you employ a “we interpret everything” policy, then you can report the studies based on the number of views you interpret. Films might require interpretation if the physician could not determine that the fracture was correctly aligned and needed a concomitant interpretation before finalizing the surgery.

In addition, if the orthopedist orders the pre-reduction x-rays to actually diagnose the fracture, and subsequently interprets post-reduction films to confirm alignment, your insurer should reimburse both interpretations, as long as the physician documents the services appropriately.

If the physician interprets both sets of films after completing surgery, you should count the x-rays as surgical documentation and they are therefore not separately billable. Reading the films after surgery indicates that you ordered and interpreted the x-rays for documentation purposes; if they were integral to the surgery, you would have read them during the procedure.

Hospitals with radiologists on staff may have policies that all x-rays are read by their staff radiologists. Therefore, if those radiologists interpret the films and provide a record, the surgeon cannot charge for an interpretation.

In addition, your payers might have specific guidelines precluding you from reporting any x-rays with your surgical services. Always check insurer policy, as well as the CCI edits, to ensure that you’re reporting these services accurately.