Orthopedic Coding Alert

Question: We recently saw a patient who injured his leg in a car accident. The surgeon ordered an x-ray of the affected leg, along with comparison views of the other leg. The insurer denied the x-ray claim for the unaffected leg and only paid us for a unilateral x-ray. Should we appeal?


Alabama Subscriber

Answer: Probably not. Although your payer may reimburse comparison views of children's legs, you can't usually collect for comparison views that you take of adult patients.

Surgeons sometimes order comparison views of children because they suspect growth-plate injuries, and comparing the left side to the right can confirm this type of injury. But in an adult patient, the insurer sometimes considers the non-injured side a screening x-ray because you lack the appropriate diagnosis to justify medical necessity on the healthy leg.

Many insurers and Medicare carriers publish their comparison x-ray guidelines. The National Coverage Determination for Cahaba Government Benefit Administrators (a Part B carrier in Alabama), for instance, states, -Bilateral radiographs, for -comparison- of a symptomatic knee with a patient's asymptomatic knee, are not usually medically necessary in the adult patient.-

If your physician believes that he requires the comparison view for medically necessary reasons, you should submit the claims with the LT (Left side) and RT (Right side) modifiers, and include a letter in which the physician describes the medical necessity for the unaffected side. He should link the x-rays to V72.5 (Radiological examination, not elsewhere classified).