Appropriate modifier use with E/M and X-rays

HCCCoder

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Hi all, any suggestion will be appreciated.

I have this case where a new pt came in for the pain within the arm. Doctor performed the Hx, PE and MDM and also has the following note:

"X-Rays of right elbow (73080), forearm (73090), wrist (73110),
hand (73130) are negative, PA, lateral and oblique, for any bony abnormalities".

My question is, if I code this case scenario as 99201-99214 (E/M based on what was documented) with 73080, 73090, 73110, 73130, what kind of modifier I need? Or do I even need one? I assume (I did confirm this with the doctor's office) that the dr did the x-ray in his office and read the results.

Thanks anyone who will answer to my question.
 
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jackiels

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First Rule of coding: If it wasn't documented it wasn't done
Second Rule of Coding: Never Assume Anything!
 

HCCCoder

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Thank you for your response and I am well aware of those rules.
Ok, what do you mean "if it wasn't documented, it wasn't done?"
That's not my question.
And regarding the x-ray, I did confirm with the doctor and he did that in the office.
Can you please answer to my question now?

Thank you,
Lilit
 

hbsg11

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Modifier

You do not need a modifier with the visit, if all x-rays were done in MD's office.
Am I correct guys?
 

junebug1969

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I believe that you would at least need modifier -25 on the E/M service to show that the E/M service was a separate, distinct service. Other than that, I don't think you need modifiers other than directional ones (-RT) on all the X-rays.
 

HCCCoder

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Thank you very much for all your responses.
I do need some additional information regarding this. Like any supplemental web sites.
Is there someone who can help?
Thank you,
Lilit
 

pamtienter

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You don't need a modifier on the visit if you are billing only x-rays in addition to the E/M. I would agree with the RT or LT on the x-rays though.

Happy Holidays!
 
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