Monday, August 29, 2016

Procedure code 71020 - Description and coverage

Procedure code  71020

Description of Service:

Chest x-rays are noninvasive diagnostic studies to aid in the diagnosis of lung disease, cardiac conditions, bony abnormalities and chest wall conditions.

Policy :

Chest x-rays (Procedure codes 71010 and 71020) will not be reimbursed when billed with preventive evaluation/management services (Procedure codes 99381-99387 and 99391-99397) on the same date of service unless submitted with an applicable ICD-9 diagnosis code (refer to Payment Guidelines).

Most conditions do not require more than one radiologic examination per day.  Occasionally it is medically necessary to repeat chest X-rays for medical conditions such as, but not limited to, the evaluation of pleural effusions, thoracic trauma, post thoracentesis, post pneumothorax evacuation and post central venous catheter placement.

Under these circumstances, the following applies:

Procedure-4 code 71010 is reimbursable more than once on the same day, for the same recipient and same provider.

Procedure-4 code 71020 is reimbursable more than once on the same day, for the same recipient and same provider.

The combination of Procedure-4 codes 71010 and 71020 is reimbursable on the same day, same recipient and same provider.

When billing for Procedure-4 code 71010 or code 71020 with a quantity greater than one, providers should include supporting information or an explanation in the Remarks field (Box 80)/Additional Claim Information field (Box 19) of the claim.  Failure to supply supporting information may result in claim denial or a reduction in payment.  Additionally, quantities greater than one must be billed on a single claim line.


Treatment/Application Guidelines:

Oxford provides coverage for chest x-rays that are medically necessary based on signs, symptoms, illnesses, injuries or diseases.

Specific symptoms or findings such as cough, hemoptysis, dyspnea, recent conversion of a T.B. skin test from negative to positive, or fever of undetermined origin constitute medical necessity for performing chest x-rays.

Medical conditions with manifestations involving chest structures such as metastatic carcinoma or congestive heart failure are indications for performing a chest x-ray.

Chest x-rays are covered when performed to follow-up an invasive procedure such as thoracentesis or central venous line placement.

Preoperative chest x-rays are covered if the patient is scheduled for major surgery and has risk factors which make the x-rays necessary. The risk factors must be clearly stated in the patient's medical record.

Chest x-rays performed routinely, for screening purposes, for pre-operative clearance, or as part of a periodic examination in the absence of symptoms, signs or disease states (as represented by the codes listed in the "ICD-9 Diagnosis Codes Reimbursable During Routine Care" section) will not be covered.

Pre-operative chest x-rays routinely ordered for all patients undergoing a surgical procedure will be considered non-covered under the screening exclusion. For pre-operative x-rays to be covered, the patient must have a condition or symptom, which requires assessment or reassessment prior to surgery.

Only one interpretation per study is allowed.

Procedure Code 71020 – Radiologic examination, chest, 2 views, frontal and lateral


Procedure modifier 59 may be reported if, later in the day following the insertion of a chest tube, the patient develops  a high fever and a chest x-ray is performed to rule out pneumonia. Procedure code 71020 should not be reported and Procedure modifier 59 should not be used for a chest x-ray that is performed following insertion of a chest tube in order to verify correct placement of the tube. Procedure modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.

Coverage Guidance


A chest X-ray (CXR) is a two-dimensional picture of the structures within the chest, made by passing X-ray radiation through the body onto film or a digital array that captures the image.

Indications:

The information from the chest X-ray must be needed to diagnose or treat the patient. When the X-ray is not needed to diagnose or treat the patient, it is not reasonable and necessary and not covered


A chest X-ray is reasonable and necessary:

To detect fluid, masses, fractures, and other abnormalities within the chest;

• To assure that an operation can be safely performed, for patients who have signs or symptoms of cardiopulmonary disease, or a disease that may manifest itself in the chest (e.g., a history of breast cancer);

• To evaluate cardiac disease, including abnormalities that change the size, shape, or radiographic appearance of the heart, lungs, aorta, esophagus, thymus, thyroid, mediastinum, airways, and related structures;

• To check the position of catheters, wires, tubes, devices, and foreign bodies located within the chest cavity;

• To detect recurrence of cancer potentially metastatic to the lung;

• To assess known or suspected injuries from chest trauma, and

• To evaluate chest skeletal structures.


• To assess pulmonary disease;

Generally, carriers must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier “-77”) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.

When carriers receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.

When carriers receive multiple claims for the same interpretation, they must generally pay for the first bill received. Carriers must pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed.

Consideration is not given to designation as the hospital’s “official interpretation” as a factor in determining which claim to pay. Carriers pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary.

Billing and Coding Guidelines

Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure.

Procedure Code 32551 – Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open

Procedure Code 71020 – Radiologic examination, chest, 2 views, frontal and lateral

Modifier 59 may be reported if, later in the day following the insertion of a chest tube, the patient develops a high fever and a chest x-ray is performed to rule out pneumonia. Procedure code 71020 should not be reported and modifier 59 should not be used for a chest x-ray that is performed following insertion of a chest tube in order to verify correct placement of the tube.

Critical Care Services - Codes 36000, 36410, 36415, 36591, 36600, 43752, 43753, 71010, 71015, 71020, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, and 99090 are considered incidental to 99291 and 99292(Critical Care Services). Critical care service procedures will be denied as incidental when submitted with Neonatal and Pediatric Critical Care services (99466, 99467, 99468, 99469, 99471, 99472, 99475, 99476). The critical care service procedures are included in the pediatric and neonatal critical care codes. Separate reimbursement is not allowed for incidental services.


Consultation on X-ray examination

When billing a consultation, the consulting physician must bill the specific X-ray code with modifier 26 (professional component).

For example: The primary physician would bill with the global chest X-ray (CPT code 71020), or the professional component (CPT code 71020-26), and the consulting
physician would bill only for the professional component of the chest X-ray (e.g., CPT code 71020-26).

Coronary artery calcium scoring

The agency does not recognize computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium as medically necessary.

Prior authorization from the agency is required for CPT code 75571. Consultation on X-ray examination When billing a consultation, the consulting physician must bill the specific X-ray code with modifier 26 (professional component).

For example: The primary physician would bill with the global chest X-ray (CPT code 71020), or the professional component (CPT code 71020-26), and the consulting
physician would bill only for the professional component of the chest X-ray (e.g., CPT code 71020-26).

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