“I know United Healthcare changed the processing of claims for podiatrists this year when an office visit is billed with an x-ray. However, now I am seeing the same issue with Anthem Blue Cross Blue Shield. New patient office visits are even being denied when billed with an x-ray. We have an x-ray unit on site, take our own x-rays, and our podiatrists read the x-rays. Do you have any advice for how to dispute some of these new patient office visits that are being denied as being included in the payment for the Xray?”
This is becoming a fairly common denial, particularly when Medicare Advantage plans and some commercial payers apply edits that incorrectly bundle a new patient E/M service (99202–99205) into payment for an in-office X-ray. In many cases, these denials are appealable.
Step 1: Determine the Actual Denial Reason
Before appealing, identify the exact denial code. Common reasons include:
- "Included in the payment for another service."
- "Procedure incidental to another procedure."
- NCCI edit
- Modifier missing
- Global surgery edits (usually not applicable to diagnostic X-rays)
- Medical necessity denial
The denial reason determines the appeal strategy.
Step 2: Know the Medicare Rule
Under Medicare, obtaining and interpreting a medically necessary diagnostic X-ray does not, by itself, include the office E/M service.
If the physician performed a medically necessary evaluation that resulted in the decision to order the X-ray, reviewed the images, interpreted the findings (if appropriate), and developed a treatment plan, the E/M service is generally separately payable when documentation supports the selected level.
CMS E/M guidelines allow reporting an E/M service when the documentation supports the level of medical decision making or total time, independent of the X-ray itself.
Step 3: Review the Documentation
The chart should demonstrate that the E/M was more than simply obtaining an X-ray.
Strong documentation includes:
- Chief complaint
- History of present illness
- Review of prior records (when applicable)
- Independent history, if obtained
- Physical examination
- Differential diagnosis
- Decision to order imaging
- Interpretation/review of imaging
- Treatment recommendations
- Discussion of options
- Follow-up plan
For a new patient, documentation should clearly establish that the physician performed the work required for a new patient evaluation.
Step 4: Verify Proper Coding
Typical example:
- 99203 – New patient office visit
- 73630-RT – Foot X-ray, minimum 3 views
- Modifier -26 if billing only the professional component
- Modifier -TC if billing only the technical component (or no modifier if billing globally and appropriate)
An E/M service generally does not require modifier -25 simply because an X-ray was performed. Modifier -25 is used when a significant, separately identifiable E/M service is performed on the same day as a procedure. Diagnostic radiology is not typically considered the type of procedure that necessitates modifier -25 solely due to being performed on the same date. However, some commercial payers may have payer-specific processing rules, so always review the payer's policy.
Step 5: Cite the Correct Coding Principles
Your appeal can point out that:
- The X-ray is a diagnostic test.
- The physician's evaluation was medically necessary before and after the imaging.
- The X-ray does not replace the physician's cognitive work involved in evaluating the patient.
- The E/M code represents the evaluation, diagnosis, and management decision—not merely the ordering or performance of imaging.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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