Cpt Code 71100 Descriptive Essay

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Reporting and Documentation Rules and Criteria for Modifier 59:

The reporting of modifier 59 by a provider must follow the Health Plan’s requirements for correct coding.

• The Health Plan requires that modifier 59 must be appended to the denied code as described in the National Correct Coding Initiative (NCCI) Column 1/Column 2 edits

• We follow CPT' coding guidelines requiring that modifier 59 only be used when there is no other appropriate established modifier, and “only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.2 ” Documentation is not required for a claim to be processed when modifier 59 is appended to a CPT/HCPCS code. However, if requested, the patient's medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. The Health Plan follows CPT in requiring that documentation must support:

• a different session or patient encounter

• a different procedure or surgery

• a different anatomical site or organ system

• a separate incision/excision

• a separate lesion

• a separate injury

The following example indicates the appropriate use of modifier 59 when two procedures codes that are not ordinarily performed together on the same day by the same provider, are reported.

• A single view chest x-ray (71010) is part of the more comprehensive radiologic exam described by 74022 (radiologic examination abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest). If these two procedures are reported together, 71010 will be denied separate reimbursement.

• When a single view chest x-ray is performed on the same day but at a different time and patient encounter, appending modifier 59 to CPT 71010 is warranted to signify that a separate and distinct service was performed. (Modifier 59 should follow modifier 26, if services are done in a facility setting.) Modifier 59 will override the procedure unbundling edit and 71010 will be  eligible for separate reimbursement.

What is changing?

When CPT code 71010 and CPT code 71100 are billed for the same day, the codes will be recoded to the comprehensive CPT code or CPT code 71101.

* CPT code 71010 is defined as “radiologic examination, chest; single view, frontal.”

* CPT code 71100 is defined as ”radiologic examination, ribs, unilateral; two views.”

* CPT code 71101 is defined as “radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views.”

Why is Humana implementing this change?

CPT code 71010 is for a chest X-ray, and code 71100 is for rib views. If both views are being performed, the appropriate code to bill is code 71101, which is for the rib and chest views, per AMA’s CPT description.

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