If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. However, when you are coding an x-ray of the thumb, you will find that this is considered part of the hand and not a finger.
Let's look at the three codes we will be reviewing:
There are many reasons to x-ray just the thumb; however, when a condition requires imaging of the thumb, most of the hand and fingers are visible in that same x-ray. As such, when images of the hand and fingers are performed on the same hand during the same encounter an NCCI edit will occur that states that unless an appropriate modifier is reported, meeting the appropriate circumstances, the images of the hand will be paid and the fingers will be denied as inclusive.
The patient is a 12-year old boy whose sister slammed his right hand into the van door when closing it. Two views of the right thumb and two views of the right hand were taken, revealing no fractures.
Appropriate coding would include: Two views of the thumb (73140) Two views of the hand (73120).
Find-A-Code has an NCCI Edit Validation tool available on the Home Page. Using this tool you can simply enter these two codes, click on Validate and any warnings or instructions related to the NCCI edits will appear at the bottom of the screen.
When we run these two codes through the Find-A-Code NCCI Edit Validator we get a warning that there is an edit associated with 73120. As 73140 is a Column 2 code when both 73120 and 73140 are reported together, only 73120 will be paid.
It also states that you can get around this edit if the appropriate circumstances exist by appending modifier -59 to code 73140.
What would be considered 'appropriate circumstances' in which you could append -59? Obviously, it's not because your providers states, "Well I did both, so I should get paid for both!" Although, I have heard that theory before, it just doesn't cut the mustard.
Appropriate circumstances would include something like the following:
Patient suffered injury to his left thumb and right hand when he fell down the stairs and put his hands out to try and stop himself. Patient complains of left thumb pain that radiates into the wrist and right first and second fingertip pain. Radiographs, including two-view of the left thumb and two-view of right first and second fingers were taken, revealing swelling without evidence of fractures.
In this case, it would be appropriate to report 73120-LT (thumb x-ray) and 73140-59-RT (fingers). Modifier -59 is required to indicate to the insurance company that the procedure is performed separately from the x-ray of the left thumb (73120) and modifier -RT indicates that it was performed on the fingers of the right hand.
Under these circumstances and with correct coding, both radiographs should be paid.
Don't forget the global components of TC and 26 when coding for radiology services in which your provider did not own the equipment or perform the actual x-ray but was contracted to simply review the images and report on them.
Modifier 26 is used to report a provider who simply reviews the images and reports on them. TC modifier would be billed with the code to report the use of the x-ray machine. If the provider both owns the equipment and reviews the films and creates a report, then no modifier is appended to the CPT code to report the x-ray.
Dr. Jones sent his patient for a three-view x-ray of the left thumb at XYZ Radiology. When the x-ray was taken and films were reviewed and a report created by Dr. Smith who is contracted by the hospital to read and review all of their x-rays. When the report was complete and sent back to Dr. Jones, he then reviewed the results with the patient.
How is this billed?
XYZ Radiology will bill 73130-TC-LT to be paid for the use of their equipment.
Dr. Smith will bill 73130-26-LT to be paid for reviewing and writing up a report of the findings.
Dr. Jones will most likely bill for an evaluation and management (EM) service to review the results with the patient and determine further treatment.
If the patient sees Dr. Jones who owns the x-ray equipment, takes the x-ray, reviews the films and writes up a report, he can then charge 73130 with no modifier to be reimbursed for the complete global service and will receive full reimbursement.
It is important to note that when reporting either modifier 26 or TC, these are payment modifiers and must be reported in the first modifier box. This is important when you may be specifying LT or RT at the same time and therefore have two modifiers to report. Always report modifier 26 or TC first and then in the second modifier box you can specify RT or LT.
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.
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