Effective Jan. 1, 2017, "FX" is a new Medicare modifier used to indicate that X-ray images were taken using film. The FX modifier is appended to the global radiology code or the radiology code with the modifier TC (technical component) when submitting Part B claims to Medicare and using film instead of capturing X-ray images digitally. If your images are in digital format, you do not need to change your reporting at this time. Medicare reduces payment amounts under the Physician Fee Schedule (PFS) by 20 percent of the technical component when the FX modifier is appended. If a global radiology code is submitted (the X-ray code without a 26-modifier indicating the professional component or TC-modifier) a 20 percent reduction is taken off the technical component only (Table 1). 

Few orthopaedic surgeons are currently using analog (film) imaging, however, many replaced this old technology with computed radiography (CR). Computed radiography is defined as cassette-based imaging that uses a reader to scan exposed phosphor plates sending digital images to a printer or Picture Archiving and Communication System (PACS). This is different from digital radiography (DR) that uses non-cassette imaging receptors transferring image data directly from the detector to a review monitor or printer without a reader. The Consolidated Appropriations Act of 2016 outlined a reduction in the reimbursement to the technical component for X-ray claims using CR technology beginning in 2018. Initially the reduction to the technical component will be 7 percent, increasing to 10 percent in 2023. There is no indication of what modifier will be used beginning in 2018 to indicate the use of CR on Medicare claims. There is no reduction for DR. (Table 2)

Business offices must carefully evaluate claims to ensure that only the technical component is reduced when reviewing the explanation of benefits (EOB). Groups using CR need to consider future reductions that will apply beginning in 2018.

In addition to introducing the FX modifier and the payment reduction for the technical component when film is used, relevant changes were made to Medicare's 2017 National Correct Coding Initiative (NCCI) guidelines. Radiology guidelines that impact orthopaedic surgery are the following:

1. "When a comparative imaging study is performed to assess potential complications or completeness of a procedure (eg, post-reduction, post-intubation, post-catheter placement, etc.) the professional component of the CPT code for the post-procedure imaging study is not separately payable and should not be reported.  The technical component of the CPT code for the post-procedure imaging study may be reported."
2. CPT codes that describe the radiologic examination of the entire spine (72081-72084), are not to be reported with the radiologic examination of specific regions of the spine (72020-72120). If a physician orders X-rays of the entire spine described by CPT codes 72081-72084, and, on the same patient during the same encounter, performs specific spinal views (72020-72120), the physician should add the total number of views and report one of the following:

• 72081 Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view
• 72082 2 or 3 views
• 72083 4 or 5 views
• 72084 minimum of 6 views

3. Medicare considers CPT code 73630 (radiologic examination, foot; complete, minimum of 3 views) to include the following:

• 73650 (radiologic examination; calcaneus, minimum of 2 views) and/or
• 73660 (radiologic examination; toe(s), minimum of 2 views)
• X-rays of the toes and calcaneus should not be reported to Medicare on the same date of service as X-rays of the foot to Medicare.

Finally, the 2017 NCCI guidelines warn that a physician should not report a diagnostic ultrasound and CPT code 76942 (ultrasonic guidance for needle placement…) when performed in the same anatomic region on the same date of service. Additionally, physicians should not attempt to avoid these edits by requiring the patient to have the procedures performed on different dates of service.   

Remember that the FX modifier for imaging done using film, proposed future reductions to reimbursement when computed radiography is used, and NCCI edits are specific to Medicare reporting. It is always important to consider these Medicare reductions and restrictions when contracting with other payers who state in their contracting language that they expect physicians to report services, or they will edit claims per Medicare guidelines.

Margaret M. Maley, BSN, MS, is a consultant with KarenZupko & Associates. She will speak at the 2017 Annual Meeting on Tuesday, March 14, and will answer questions at the Learning Resource Center.