Wiki BCBS CO spine denials/ requesting I use a different code

[raechelz]

I'm looking for opinions on whether my argument is correct and if anyone has seen this as well. No other BCBS in any of my other states have this edit and I am unable to find the policy.

Denial- X-ray of cervical, thoracic, and lumbar are denied as not paid separately. None of the codes are paid. We are being asked to use the entire spine x-rays.

Codes: 72040 for cervical, 72070 for thoracic, 72100 for lumbar. Requesting I use 72081-72084.

My argument- No cci edits and 72081-72081 are done with a different technique that not all machines can do. The 72081-72084 series is when the full spine is imaged on one film or a stitching software is used to line up the images to look at the full spine together.

BCBS response from medical director-

All of the claims were denied because the provider billed 72040, 72070 and 72100 together. 72100 (Radiologic examination, spine, lumbosacral; 2 or 3 views), was denied because it was billed on the same date of service as the denied procedures 72040 (Radiologic examination, spine, cervical; 2 or 3 views) and 72070 (Radiologic examination, spine; thoracic, 2 views), per our policy. A radiological exam of the entire spine includes a radiological exam of the cervical spine, of the thoracic spine and of the lumbosacral spine. Therefore, when these procedures are performed together, they should not be billed separately.

We reviewed this edit as well as a medical director with coding expertise took a look and believe the edit to be correct. Rather than reporting out each individual spinal x-ray (unbundling), the more comprehensive code which represents x-rays of all the anatomical sites of the spine and the total number of views is coding to the highest level of specificity. (72081-72084).

 

[thomas7331]

Radiology isn't my specialty, but in reviewing the coding I think I would agree with the medical director's decision here. I can't find any direction in CPT or the supporting guidance that specifies that the use of codes 72081-72084 is reserved only for cases where the imaging must be done on a single machine or requires 'stitching software'. In fact, the CPT descriptions in the codes does specify the number of views included in any one of these codes which suggests that intention was to encompass studies that do require separate images in the study. Although the codes you billed to not have CCI edits with each other, they do bundle to CPT codes 72081-72084, which indicates that they are considered components of the more comprehensive procedure. This is a similar situation to what a lab would encounter if they billed the individual components of a panel for which there exists a single CPT code, e.g. a basic health panel where the lab bills each of the individual component codes instead of the panel code 80050.

In any case, your payer medical director's decision here carries a lot more weight than your or my or any other coder's opinion on the matter - whether technically correct or not from a coder's perspective, they are the ones with the authority to set payment policy for their organization. They've given you their definitive direction on this and you have it in writing and if your provider is participating with the payer, there's likely a clause in the contract that binds you to this so that's how you'll need to bill it to them. If their decision causes significant loss of revenue to your practice, you may wish to discuss it with the payer's contract representative next time your participation agreement is up for renewal, and they may be willing to give you a higher rate of payment for these codes to compensate you and give you the incentive to stay in their network.