Radiology Service Components and Unconfirmed Diagnoses
Often when a radiology service is performed, there are two components involved: a technical component and a professional component. When only the technical or professional component is provided, the appropriate modifier needs to be appended to the CPT code to indicate to the payer how that portion of the service should be paid.
There are also ICD-10-CM coding guidelines that explain how to code for an unconfirmed diagnosis. You will need to understand these guidelines for the following coding challenge.
The Coding Challenge
Question: A 16-year-old male presents to the ED with right elbow pain. The emergency physician ordered x-ray images of the right elbow from the anteroposterior and lateral positions. The radiologist provided only the interpretation and report indicating the results show no fracture, dislocation, or abnormality. Assign the CPT code for the professional component of the service, along with the appropriate ICD-10-CM code.
A. 73070-26-RT, M25.521
B. 73080-TC-LT, M25.52
C. 73070-26-RT, M25.321
D. 73080-TC-LT, M25.821
A. 73070-26-RT, M25.521
Locate and Verify
In the CPT coding manual Index, look up X-ray/elbow, 73070-73080. In the Tabular, we can verify the correct code as:
73070, Radiologic examination, elbow; 2 views
The two elbow x-rays were taken of the anteroposterior (AP) and lateral positions. We need two modifiers here:
CPT modifier -26 is usually used with radiology services since these services are often broken down into a professional component and a technical component. In this scenario, modifier -26 is appended to CPT code 73070 to show that the physician performed the professional component of the service only.
If we were being asked to assign the code for the facility’s services for the technical component only, modifier -TC would need to be appended to CPT code 73070.
HCPCS Level II anatomical modifier -RT should also be appended to 73070 to show that the services were performed on the right elbow.
Sequencing of the Modifiers
When using more than one modifier, sequencing of the modifiers may be dictated by the payer’s policy. Medicare and many payers, however, state that pricing modifiers need to be sequenced first, according to the American Medical Association (AMA) and Coding with Modifiers, 6th Edition. Modifier -26 is a pricing modifier and determines payment. Modifier -RT is an informational modifier and should be listed after the pricing modifier, making the appropriate code 73070-26-RT.
The x-ray results came back normal. Therefore, we need to assign a code for the symptom, which is the pain in the elbow. The elbow is the joint between the upper and lower parts of the arm.
“Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.”
In the ICD-10-CM coding manual Alphabetic Index, look up Pain (s)/joint/elbow M25.52-. When we go to the Tabular, we can see that a 6th character is needed. Our correct code is:
M25.521, Pain in right elbow
B. 73080-TC-LT, M25.52. 73080 refers to Radiologic examination, elbow; complete, minimum of 3 views. It also has the wrong anatomic modifier (-LT). M25.52 is an invalid code and is missing a 6th digit.
C. 73070-26-RT, M25.321. M5.321 refers to Other instability, right elbow.
D. 73080-TC-LT, M25.821. 73080-TC-LT is an incorrect code and has two incorrect modifiers. M25.821 refers to Other specified joint disorders, right elbow.