73030 – Radiologic examination, shoulder; complete, minimum of 2 views – average fee amount – $25 – $30
73040 – Radiologic examination, shoulder, arthrography, radiological supervision and interpretation average fee amount – $90- $120
73020 – Radiologic examination, shoulder; 1 view
Non-interventional Diagnostic Imaging
Non-invasive/interventional diagnostic imaging includes but is not limited to standard radiographs, single or multiple views, contrast studies, computerized tomography and magnetic resonance imaging. The Procedure Manual allows for various combinations of codes to address the number and type of radiographic views. For a given radiographic series, the procedure code that most
accurately describes what was performed should be reported. Because the number of views necessary to obtain medically useful information may vary, a complete review of Procedure coding options for a given radiographic session is important to assure accurate coding with the most comprehensive code describing the services performed rather than billing multiple codes to describe the service.
1. If radiographs have to be repeated in the course of a radiographic encounter due to substandard quality, only one unit of service for the code can be reported. If the radiologist elects to obtain additional views after reviewing initial films in order to render an interpretation, the Medicare policy on the ordering of diagnostic tests must be followed. The Procedure code describing the total service should be reported, even if the patient was released from the radiology suite and had to return
for additional services. The Procedure descriptors for many of these services refer to a “minimum” number of views. If more than the minimum number specified is necessary and no other more specific Procedure code is available, only that service should be reported. However, if additional films are necessary due to a change in the patient’s condition, separate reporting may be appropriate.
2. Procedure code descriptors that specify a minimum number of views include additional views if there is no more comprehensive code specifically including the additional views. For example, if three views of the shoulder are obtained, Procedure code 73030 (Radiologic examination, shoulder; complete, minimum of two views) with one unit of service should be reported rather than
Procedure code 73020 (Radiologic examination, shoulder; one view) plus Procedure code 73030.
LT, RT Modifier usage
Modifiers LT and RT are only considered valid for procedure codes specific to body parts that exist only twice in the body, once on the left and once on the right (paired body parts). For example, eye procedures (e.g. cataract surgery) and knee procedures (e.g. total knee replacement).
Modifiers LT and RT should be used when a procedure was performed on only one side of the body, to identify which one of the paired organs was operated upon.
LT and RT are not considered valid for toe procedures, excision of lesions, tendon/ligament injections (20550), or needle placements, etc. (Use finger and toe modifiers for finger and toe procedure codes; use eyelid modifiers for eyelid procedures.)
If the code description is for a structure that occurs multiple times on one side of the body (e.g. fingers, tendons, nerves, etc.) and is not specific enough for you to be able to mark on a body diagram where the left or right procedure is performed without looking at the medical record (e.g. place an “x” on the left shoulder for 73030-LT), then LT and RT are not valid modifiers.
(Modifier -59 may be needed to indicate a separate lesion, separate nerve, separate tendon, etc. for non-paired procedure codes.)
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
* ISSUE IN DISPUTE: Denial of CPT codes: 99285, 94770, 96360 and 94761
* Provider billed the disputed CPT codes on a UB04, bill type 131 for date of service 9/19/2014. In addition to the disputed codes, CPT 73030, 23650 and 99144 were billed. The Claims Administrator reimbursed the Provider $36.36 for CPT 73030 and $191.09 for CPT 23650.
* Based on the NCCI edits The following code pairs generally cannot be reported together: 23650 and 94770; 23650 and 96360; 94761 and 99285;
* Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation supports the use of the procedure code then the edit may be overridden
* ISSUE IN DISPUTE: The Provider is seeking additional reimbursement for CPT 94770 and 73020-RT.
* The Provider billed the disputed codes as part of an emergency room visit for date of service 5/20/2015.
* Provider billed CPT 73020-RT and 73030-RT for the same date of service. The two codes are not reported together, unless separate reimbursement supported by documentation and an appropriate modifier. The only modifier appended was RT, services were performed on the same shoulder (right). If billing for pre and post X-rays, Modifier 59 would identify the procedures as separate and services.