You don't, unless a symptom is present or the patient has a chronic condition whose progression/current status can be assessed by way of the chest x-ray.
Just like pre-op evaluations, pre-op dx tests are not paid separtely from the surgeon's global package unless it is "medically necessary" vs. being "routine screening." To Medicare, a service is "medically necessary" usually because of the fact that the patient is experiencing some symptom that requires diagnosis before the surgery in order to determine if the problem represents a reason not to perform the surgery, or to alert the surgeon to a possible cause for an intra-operative complication.
This is what Medicare's paper-based Carriers Manual says:
15047. PREOPERATIVE SERVICES
D. Preoperative Diagnostic Tests.--Tests performed to determine a patient’s perioperative risk and optimize perioperative care. Preoperative diagnostic tests are payable if they are medically necessary and meet any other applicable requirements.
2. Preoperative Diagnostic Tests.--When billing under the Physician Fee Schedule, preoperative diagnostic tests performed by, or at the request of, the physician performing preoperative examinations, do not fall within the statutory exclusion articulated in Â§1862(a)(7) of the Act. These diagnostic tests are payable if they are medically necessary (i.e., they may be denied under Â§1862(a)(1)(A)).
So it says that the dx tests must be "medically necessary" and "may be denied under Section 1862 (a)(1)(A)." This is the section of the Act that specifies that services must be performed related to a symptom being experienced.
The Carriers Manual further says:
G. ICD Coding Requirements for Preoperative Services.--All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through V72.84). Additionally, the appropriate ICD-9 code for the condition(s) that prompted surgery must also be documented on the claim. Other diagnoses and conditions affecting the patient should also be documented on the claim, if appropriate. The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81 through V72.84).
H. Medical Necessity Determination.--Medical necessity for specific preoperative services is determined by any applicable national coverage decisions. In the absence of a national coverage determination, medical necessity is determined by carrier discretion.
In the real-world application of this guideline, that bolded line above referring to "additional diagnoses" carries a lot of weight because these additional dx codes (after the pre-operative V-code and the surgery dx code) are what is used by many carriers to establish whether there was “medical necessity” for the separate billing of a pre-operative evaluation. These additional dx codes usually identify that identify a separate reason/sign/symptom/co-morbidity/hx of an illness is present that warrants the performance of a more extensive pre-operative service than the standard/routine pre-op H and P for an otherwise healthy patient (patients with no signs/symptoms other than that prompting the need for the surgery), which Medicare considers a surgeon to already be compensated for as part of the global surgical fee.
This is supported by comments by a CMS medical director in the Part B News of 4/8/02 shortly after Medicare had revised its wording on billing pre-operative services:
“"The policy clarification [from CMS] was really that if a service is reasonable and necessary, it can't be denied just because it happens to be a pre-op service," says Grant Steffen MD, a carrier medical director for Noridian Mutual Insurance Co. (the Part B carrier for Alaska, Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming). "But to be paid, [these claims] still need to have a diagnosis code [in addition to the pre-op "V" code] that supports medical necessity," Steffen says.
He gives the following example: a patient with a history of chronic lung disease would likely need to be examined by the surgeon (or the patient's primary care physician) prior to undergoing an operation. In this case, a diagnosis code of lung disease would support billing separately for the evaluation, Steffen says.”
Also from the same article:
“Another common problem: getting paid for pre-operative tests like EKGs or X-rays. Steffen says Noridian will pay for these tests, but only if there is a medically necessary reason for them to be performed - in other words, a diagnosis code other than the pre-op "V" code.
"We can usually get paid if the patient has a pre-existing condition" that may affect how they respond to the surgery, says Mary Sickel, coding and compliance officer for Temple Physicians (120 doctors), Philadelphia. But so-called "routine" pre-operative tests (performed in absence of signs/symptoms) won't be paid by her carrier, she says.”
The Kentucky Medicare carrier also clearly identifies that the additional diagnoses are key in identifying “medical necessity”:
Pre-operative examinations and pre-operative diagnostic tests, in order to be paid under Medicare, must be done based on medical necessity, not based on age or other administrative requirements of hospitals, or authorities other than Medicare. When filing claims for pre-operative services, the appropriate ICD-9-CM codes V72.81-V72.84 should be used. This communicates the nature of the examination as being pre-operative. In addition, appropriate ICD-9-CM codes for the condition(s) that prompted surgery and for the condition(s) that prompted pre-operative medical examination should be documented on the claim. ICD-9-CM code V72.81-V72.84 should appear on the line item of a pre-operative examination or pre-operative diagnostic test. The additional appropriate ICD-9-CM codes are those on which the judgment of medical necessity is carried out, establishing reasonable and necessary services based on the appropriate additional ICD-9-CM codes.
First Coast Service Options, the FL Medicare contractor, said in its 2006 E/M Guide:
Section 1862(a)(1)(A) of the Social Security Act requires that in order to qualify for Medicare coverage, a service must be reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member. A preoperative clearance performed due to hospital or malpractice protocol cannot supersede this guideline for Medicare coverage purposes.
Diagnostic tests ordered as a result of a routine preoperative consultation in the absence of any condition and/or signs and symptoms do not meet medical necessity requirements.
So you MUST bill with the V-code first, the surgery dx code 2nd, and the code, if available, for any chronic condition/active symptom being experienced that makes the chest x-ray "medically necessary" as opposed to being "routine screening." Using the V-code triggers the contractor to look for the presence of the third code that identifies medical necessity.
If you bill using the dx of the surgery only, it makes it appear as though you performed the chest x-ray to diagnose some identified symptom associated with the surgery dx, but that is actually not the case. Those who bill using the dx of the surgery only usually just don't know the rules very well, but it's also possible that some do know the rules and are just doing this to "get paid." You don't want to be in either group.
Seth Canterbury, CPC, ACS-EM