General / Hot Coding Topics

Multiple X-Ray Charges OK for Different Purposes

Question: A new patient presented to the office because of an injured left ankle she hurt while doing yard work. The FP performed a detailed history and examination. He suspected a fracture and ordered a two-view ankle x-ray, which revealed a bimalleolar fracture. The physician provided local anesthesia and used closed treatment to manipulate the fracture. He then ordered a second two-view ankle x-ray to confirm proper alignment. Notes indicated moderate medical decision making. Can I code both ankle x-rays in this scenario?

Answer: Since the physician ordered separate x-rays for different purposes (identifying the fracture, then ensuring proper bone placement), you can code for both. On the claim, report the following:

  • 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history;, a detailed examination; and medical decision making of low complexity) for the evaluation and management service that diagnosed the fracture and led to the decision to treat it.
  • 27810 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; with manipulation) for the fracture care
  • 73600 (Radiologic examination, ankle; 2 views) x 2 for the x-rays (one before the surgery, and one to ensure proper bone placement postsurgery)
  • 824.4 (Fracture of ankle; bimalleolar, closed) appended to 99203, 27810, and 73600 to represent the patient’s ankle fracture
  • E016.X (Activities involving property and land maintenance, building and construction) appended to 99203, 27810, and 73600 to represent the cause of the patient’s ankle fracture. The nature of the “yard work” that the patient was doing will determine the appropriate last digit of this code.

Modifier alert: Be sure to check with your payer before filing...

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July 1, 2011
Coding Challenge / General

Correctly Code Crush Injury of Hand

Question:
We have a patient who had a severe crush injury of the left hand which led to a comminuted fracture of the left 3rd and 5th metacarpals with an intra-articular fracture of the proximal phalanx of the left index finger.  The physician’s documentation indicates the following:

  • There was also a soft tissue defect over the left proximal interphalangeal (PIP) joint of the middle finger.  After taking samples for culture, the wounds were meticulously débrided and curetted.
  • Bony structures were evident over the 3rd metacarpal as well as on the PIP of the middle finger where the defect was about 3-1/2 to 2-1/2 inches. The area of the dorsum of the PIP joint of the left middle finger was about ¾ inch x ¾ inch.
  • Debridement and irrigation was done using 6 liters of saline with the gravity Patzakis technique and 1 liter of antibiotic.
  • After the wound was washed, X-rays were taken to confirm the fractures though no attempt was made to reduce any fractures because of the severe contamination.  A wound-VAC was planned for the dorsum of the left hand at the PIP joint of the left small finger.

Would I report 11043 and 97605 with ICD-9 682.4 and 681.00?

-North Carolina Subscriber

Answer:
The correct codes in this situation would be 11010 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and
subcutaneous tissues), 11011 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle), or 11012 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and...

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June 17, 2011
Coding Challenge / modifier 50

Is Modifier 50 OK for Bilateral Radiology Exams?

Question: Our physician x-rayed a patient’s symptomatic knee and ordered an x-ray of the other knee for comparative purposes. How should we report the comparison x-ray? Answer: Report the appropriate radiology code on two separate lines of your claim...

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February 16, 2011
Hot Coding Topics

Therapy Progression Is Your Key to Correct Whiplash Coding

Be on a look out for Scans, TPIs, and more

Though coding for whiplash diagnosis and treatment is pretty straightforward, you should still watch out situations when the patient’s symptoms persist despite conservative therapy and warrant more extensive treatment. You will miss your pay if you miss these diagnoses.

When a patient presents with whiplash symptoms, your pain management specialist will conduct a thorough exam and will often order neck x-rays to rule out fractures. On diagnoses of whiplash (847.0, Sprains and strains of other and unspecified parts of back; neck sprain), he typically will prescribe conservative treatment. Common options include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients may also benefit from wearing a soft cervical collar or by using a portable traction device.

If conservative treatment fails, the physician might order additional diagnostic imaging tests. These could include:

  • CT scans – 70490 (Computed tomography, soft tissue neck; without contrast material), 70491 (… with contrast material[s]) and 70492 (… without contrast material followed by contrast material[s] and further sections)
  • MRIs – 70540 (Magnetic resonance [e.g., proton] imaging, orbit, face and/or neck; without contrast material[s]), 70542 (… with contrast material[s]) and 70543 (… without contrast material[s], followed by contrast material[s] and further sequences)
  • Bone scans – CT, MRI, and x-ray tests include basic bone scans. If your physician orders more extensive bone scans for the patient, you might to get authorization for 78300 (Bone and/or joint imaging; limited area) or 78305 (… multiple areas) instead.

Correctly Count Trigger Point Injections

Your physician might also administer trigger point injections to relieve the patient’s pain and muscle tenderness. Code these procedures with 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (…three or more muscles).

Because of the “one or two muscles” and “three or...

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February 5, 2011
Hot Coding Topics

73090 Bundles Will Cost You $26 Unless You Correctly Apply Global Package

Depending on how many x-rays you write off, you could be losing thousands.

Myth: X-rays that you shoot or interpret during the global period are not billable to Medicare because payers include these charges in the surgical package.

Reality: Bill Those Follow-Up X-Rays

The challenge: You should report fracture care (25600, Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) and any x-rays performed for the initial visit. But can you report the follow-up x-rays? The solution:

X-rays determine the patient’s condition and the course of care, so they are not included in global packages. You can also report any follow-up x-rays separately. If you don’t separately report the x-rays, you risk losing significant reimbursement.

Because Medicare payers will reimburse about $26 each time you report 73090, failing to report the x-rays could be an expensive mistake over the course of a year.

When a fracture care code is selected, this only includes the initial casting and all follow-up visits within the 90 day global period. All x-rays, subsequent castings and supplies are not included in the fracture care code. These services and supplies are not considered as edits or mutually exclusive codes by NCCI.

Billing x-rays outside of the global period doesn’t apply only to fracture care claims. In fact, diagnostic services are not considered part of the global package in general, and may be billed separately.

“Per the American Academy of Orthopaedic Surgery’s Global service data guidelines and CCI, the only x-rays that are included in a procedure are those that are intra-operative, such as checking the placement if a manipulation was performed before the cast was placed,” Williams advises. “X-rays that are taken pre- and post-reduction , i.e. before...

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September 16, 2010
Coding Challenge / E/M / modifier 25 / modifier 26 / radiology

Use 3 CPT, Modifier, and ICD-9 Code Pairs to Ace This X-Ray Claim

Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9 codes. On the claim, report the following:

  • 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the x-ray
  • Modifier 26 (Professional component) appended 71020 to show that you are coding for the physician’s services only
  • 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination;and Medical decision making of moderate complexity….) for the E/M
  • Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 show that the E/M and the x-rays were separate services
  • 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99284 to represent the patient’s URI
  • 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99284 to represent the patient’s focal ronchi.

Secondary Dx decoded: Even though the focal ronchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient’s condition, and can only strengthen your medical necessity case for the chest-x-ray.

@ Part B Insider. Editor:...

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May 24, 2010
General

Revision of a Tricuspid Valve – Why is it necessary?

The tricuspid valve is the atrioventricular valve in the right hand section of the human heart, which regulates the flow of blood from the right atrium (top chamber) to the right ventricle (the bottom chamber).

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August 11, 2009