Orthopedic Coding Alert

Orthopedic practices that refer patients for x-rays should always record the x-ray order in the patient's chart and avoid billing for the professional component of x-ray rereadings if another physician has already written a report of the x-ray findings.

Following are some of the most commonly asked orthopedic x-ray coding questions with tips on how to streamline claims processing.

Bilateral Hip Studies Include Three Views

CPT offers two codes for unilateral hip x-ray studies: 73500 (Radiologic examination, hip, unilateral; one view) and 73510 (Radiologic examination, hip, unilateral; complete, minimum of two views). The coding for bilateral exams is slightly more complex. Because 73520 (Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis) includes the anteroposterior (AP) view, many practices believe that they must x-ray the AP view of the pelvis twice to qualify for the bilateral code.

Fortunately, this is not the case. According to the April 2002 CPT Assistant , the bilateral hip study includes three views: one AP view of the pelvis, which includes both hips, and one frog-leg lateral of each the right hip and left hip.

"However," CPT Assistant says, "if a bilateral study is performed without an AP view of the pelvis, then code 73520 may be reported with modifier -52 (Reduced services) appended to indicate that the study was not performed in its entirety. CPT code 73510 is not intended to describe a bilateral hip study, but a complete radiological examination with a minimum of two views performed of a single hip."

CPT Assistant adds that if the orthopedist separately orders right and left hip studies and the interpreting physician signs separate interpretations and reports, the practice can code 73510 twice with modifier -59 (Distinct procedural service) appended to the second code.

Remember that your practice can bill the full fee for the radiological codes only if you own the x-ray equipment, says Donna Hutchins, coding manager at Riggs Orthopaedic Center in Louisville, Ky. Otherwise, Hutchins says, you should only bill the appropriate CPT code with modifier -26 (Professional component) appended. The lab performing the x-rays would bill the same code with modifier -TC (Technical component) appended to its claim.

Don't Double-Bill X-Ray Readings

Because many orthopedic patients are referred from the emergency department (ED) or by another physician, they often bring x-rays and a report of the findings to their first orthopedic visit. The orthopedist normally reviews the x-rays again, but this "reread" of the films cannot be billed using the x-ray code and modifier -26, says Jennie Horner, CPC, lead biller/coder at SOMC Medical Care Foundation in Portsmouth, Ohio.

"The additional review of the x-rays should be factored into the E/M for the day and should not be billed separately with another modifier -26," Horner says. "The insurance carriers view this as no different than reviewing any other tests," and, therefore, the reread should be applied to the medical decision-making portion of the patient's office visit.

Section 15023 of the Medicare Carriers Manual advises radiology claims processors, "When you receive multiple claims for the same interpretation, generally pay for the first bill received." Although this direction sounds simple to follow, many orthopedic coders take this to mean that they should hastily submit claims for x-ray rereadings using modifier -26 to beat the referring physician or ED radiologist to the punch. This way, Medicare pays the referring physician for his technical work in taking the x-ray and reimburses the orthopedist for his or her reread. However, this is inappropriate, and orthopedic practices are urged to avoid this type of "creative" coding.

The only exception to this rule is in the rare instances when the orthopedist finds something on the x-ray that the referring physician did not include in the report, such as a fracture. In this case, the orthopedist should bill using the applicable x-ray CPT code with modifiers -26 and -77 (Repeat procedure by another physician).

Note: Modifier -77 should be reported only when a procedure is repeated on the same date of service. The orthopedic practice should send along the patient's chart notes with a hard copy of the claim to indicate medical necessity to the insurer.