June 2000 Bulletin

How to get credit for comprehensive ROS

Reimbursement for fluoroscopy requires correct code

By Margie Scalley Vaught

This month’s Coding Corner features answers to some of the questions that readers have sent to the Bulletin.


I am a full-time hand surgeon with a relatively narrow practice focus. How do I code for consultations utilizing some of the new E/M guidelines since the review of systems (ROS) is so narrow?


In the review of systems area for the 1997 guidelines, you will see that for a detailed ROS, you need 2-9 systems reviewed and for a comprehensive you need 10 and over. Those systems are: Constitutional; Eyes; Ears, Nose, Throat, Mouth; Cardiovascular; Respiratory; GI; GU; Musculoskeletal; Integumentary (skin and/or breast); Neurological; Psychiatric; Endocrine; Hematologic/ Lymphatic; Allergic/Immunologic. You can obtain the ROS yourself, or from a form completed by the patient or obtained by one of your office staff. If you have recorded in the patient’s record 10 systems plus a statement that the other four systems were negative, you will get credit for a complete ROS. You are reviewing the systems to determine comorbidity and it makes no difference what your specialty is.


I own a fluoroscopy unit in my office, and I am finding it increasingly difficult to get reimbursed, mostly by Medicare and now by some of the MCOs. The code I use is 76000. The unit is used for any indications where a plain X-ray may be used. Why is it so difficult to get reimbursed, and how can I fix this situation?


When you state you use it "for any indications where a plain X-ray may be used" may be part of the problem. According to the code 76000, it is designated as a separate procedure. The CPT assistance’s states, "From a CPT coding perspective, those codes designated as separate procedures are only reported when performed independently of, and not immediately related to, other services." (CPT supplied the underline and italicized portion.) You will need to check with your individual Medicare Carrier and your MCOs to see how and if they will reimburse for the use of your fluoroscopy unit. Code 76000 was never intended to be used as a substitute for an X-ray code. It was for use during a procedure. Use unlisted code 76499 and append a note stating the study was similar to an X-ray code viewing the same anatomic area.


Is a subacromial decompression (29829) considered an inclusive part of a rotator cuff repair (open 23410-12 or scope 29909-no specific code)? Is a subacromial decompression considered an inclusive part of a partial claviculectomy (23120) or an AC joint resection (29909-no specific code)? Or can it (29826) be billed in addition to the rotator cuff repair, partial claviculectomy, or AC joint resection?


Since you have already done extensive research by asking five orthopaedic surgeons who perform these procedures, reviewed the procedures in Campbell’s Operative Manual, and looked at each component in the Global Service Data for Orthopaedic Surgery, and still have mixed answers, you know that this is a gray area. All components included in the procedure for Rotator Cuff Repairs listed in the Global Service Data need to be looked at. Notice that there is a description of what is included and then "examples" of possible codes. One needs to read the descriptions and not just assume those codes are the only things included in that procedure. Then it becomes an issue of ethics for the surgeon. Is part of the procedure inherent or really in addition to what is being done? Each case is going to be slightly different, hence, the AAOS produced the Global Service Data book as a guide to help surgeons see what can and can not be included in procedures. Again, this is just a "guide" and the surgeon is the one who will need to make the final judgment/decision to support what he or she believes was done. In making that decision, the surgeon will need to be able to support it with the appropriate documentation. Remember that code 29826 is for "Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release." You cannot code for any arthroscopic procedure if it is followed by an open surgical procedure in the same region or joint.

Margie Scalley Vaught, CPC, is an independent coding specialist in Ellensburg, Wash. She also is a member of the American Academy of Professional Coders National Advisory Board.

Answers to common coding questions may be addressed in future editions fo the Bulletin. Fax (847) 823-8026.

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