Sunday, October 23, 2011

71010 and 71020: Look out For Common Documentation Downfalls

Enhance Your X-Ray Services by Understanding Views

A chest X-ray's professional fee is simply $10 or so. Multiply this amount of $10 by the number of services you carry out, however, and you'll then realize how accomplishing these claims right is imperative to your practice's financial health. Read on this expert radiology medical coding article and take a step closer towards accurate and profitable radiology coding.

Actually, 71010 (Radiologic examination, chest; single view, frontal) as well as 71020 (Radiologic examination, chest, 2 views, frontal and lateral) come second and third on the list of the topmost 10 codes radiologists described to the CMS database.

Below, you'll find 71010 and 71020 basics, with example services, typical supporting diagnosis codes, as well as expert radiology coding advice on sidestepping the most common causes of audit-related denials.

Improve Your X-Ray Services by Understanding Views

Every 71010 or 71020 service might involve simply a few minutes of the radiologist's time. Normally, she makes a rapid review of the patient's history, understands the exam conducted by the technician, dictates and then signs the report, and finally shares the results with the ordering physician.

The important element differentiating 71010 from 71020 is certainly that the first signifies a single "frontal" view and the second signifies two views, "frontal and lateral."

71010: Remember, the documentation process for a 71010 service may denote an "AP view." AP means anterior-posterior, meaning the X-rays goes from the anterior (front) to the posterior (back) of the patient.

You also might find reference to a "PA view" (posterior-anterior), wherein the X-rays pass from the back to the front of the patient. The AP view could be more challenging to read than a PA view as quality issues and the way the heart seems enlarged on an AP view. Therefore, providers often have a preference to the PA view over the AP view.

You normally will find an AP view while the patient is unable to stand for the imaging service. Accordingly, a different term you'll regularly see related to 71010 services is "portable," implying that the tech carries out the X-ray with the help of a portable machine. You might find this mainly for services carried out at bedside for inpatients.

71020: You might find a 71020 service mentioned as a 'PA & Lat.' The abbreviation talks about the PA (posterior-anterior) view as well as the Lat (lateral) view. Lateral implies "side." Normally, the tech will take a left lateral X-ray, implying that the patient's left side is nearer to the film than the right side is. However the ordering physician might request for a right lateral X-ray instead.

For instance: A patient with a history of lung cancer comes with a complaint of fever and shortness of breath. Her oncologist orders PA and lateral X-ray imaging. The interpreting radiologist must report 71020. Keep in mind that you should append modifier 26 only if you're reporting the professional component.