How to Report Imaging (X-Rays) of the Thumb

March 18th, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Categories:   CPT® Coding   Diagnosis Coding   Modifiers  

If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all of the joints in between. How you code a radiograph that includes the thumb depends on what is being looked at, as well as any NCCI edits that may exist between the imaging codes being reported.

Let's do a quick review of the anatomy associated with the thumb: 

  • Thumb
    • distal phalanx (bone tip)
    • proximal phalanx (nearest the joint)
  • Hand
    • first metacarpal bone
  • Wrist
    • Carpal bones (usually trapezium or scaphoid as related to thumb injuries)
  • Joints
    • Interphalangeal (IP): Where the distal phalanx and proximal phalanx connect
    • Metacarpophalangeal (MP): Where the proximal phalanx and first metacarpal bone connect
    • Carpometacarpal (CMC): Where the base of the first metacarpal and the trapezium connect 

Most fractures of the thumb, approximately 80% of them, are actually fractures of the first metacarpal bone, which is a hand bone and not the bones of the thumb (distal/proximal phalanx). Two common fractures of the first metacarpal (hand) include: 

  1. Bennett’s type: Single fracture at the base of the first metacarpal
  2. Rolando type: Multiple fractures at the base of the first metacarpal

When the documentation refers to the first metacarpal as a “fracture of the thumb,” it can cause confusion for coders, which is why understanding the anatomy makes all the difference. Codes for reporting imaging of the bones of the thumb, hand, and wrist include: 

  • 73140 – Finger(s) (min 2 views) (e.g., distal and/or proximal phalanx)
  • 73120 – Hand (min 2 views) (e.g., first metacarpal)
  • 73130 – Hand (min 3 views) (e.g., first metacarpal)
  • 73110 – Wrist, complete (min 3 views) (e.g., trapezium, scaphoid)

An image of just the hand almost always includes some view(s) of the fingers, thumb, or wrist – it is just inevitable since we are talking about imaging such a compact and small area. However, attention should be paid to the imaging order from the physician (what was ordered and why) and what was actually produced. If there isn't enough detail to clarify the order, a provider query identifying the issue should be submitted and waited upon for a response before the final code assignment is made.

Additionally, the final diagnosis code assigned to the encounter must support the imaging performed, either with an injury code or a condition, symptoms, or disease code. If imaging is done "in-house," the documentation must identify a reason for the order, that the provider requested the imaging and why, along with documentation of the findings, which could shed further light on the situation as well. 

When imaging is focused on a potential problem with the CMC joint, or the carpals nearest the thumb (trapezium or scaphoid), report code 73110 (see CPT Assistant 2018; Diagnostic Radiology (Diagnostic Imaging) for imaging of the wrist.

If imaging is focused on the first metacarpal or metacarpophalangeal (MP) joint, report the appropriate 73120-52 (single view), 73120 (2 views), or 73130 (3 views) of the hand.

If imaging is focused on the injury located at the interphalangeal (IP) joint, report 73140.

However, in those instances when the provider isn't exactly sure where the injury may be located or the extent of the damage and as such, orders multiple images of the fingers, hand, and wrist, the National Correct Coding Initiative (NCCI) edits provide guidance important for proper reporting of the images. 

Example:

A 14-year old male presents with swelling, pain, and immobility of the right thumb following a wrestling match, with pain extending into the wrist. Following examination, the provider orders a 3-view x-ray of the hand and thumb and a 3-view x-ray of the wrist. The final diagnosis is a closed Bennett’s fracture of the right hand, initial care (S62.211A). Surgery is scheduled for ORIF of the right first metacarpal base fracture.

A review of the actual images produced included more views than originally ordered, including: 

  • 3 views of hand (73130)
  • 2 views of the thumb, which also captured the index and middle fingers (73140)
  • 3 views of the wrist, with attention to the MP and CMC joints and trapezius (73110)

Plugging these codes into the Find-A-Code NCCI Edit Validation tool reveals an edit between 73140 and 73130, with an NCCI indicator of “1.” The "1" indicates that under the appropriate circumstances, an NCCI modifier, such as modifier 59, or RT and LT, could be appended to code 73140 to override the edit. But, how do you know when it is appropriate to override this NCCI edit?

There are two main reasons for overriding an NCCI edit:

  1. The service was performed at a different encounter (on the same day and same patient)
  2. The service was performed on a different (non-contiguous) anatomic site

Since both 73140 and 73130 were performed during the same encounter and anatomic site (thumb and hand being contiguous sites), it is appropriately bundled for the circumstances and not eligible for modifier 59.

The following is an example of a circumstance in which an NCCI modifier would be appropriate to override the NCCI edit:

Example 2:

A 32-year old female suffered a traumatic injury to her left thumb and right hand after falling down the stairs about an hour ago. She admits to stretching out her hands to try and break her fall. She complains of left thumb pain that radiates into the wrist and pain in her right index and middle fingers. Radiographs, including 3 views of the hand including the thumb and 2 views of the fingers of the right hand (with particular attention to the index and middle fingers) were ordered and done in the office. Imaging revealed no evidence of fractures in either the thumb, hand, or fingers. 

In this case, it would be appropriate to report 73130-LT (hand with thumb) and 73140-RT (fingers). Modifier 59 would not be required, as HCPCS modifier RT and modifier LT accomplish the same thing (identifying different anatomic sites). Additionally, the correct ICD-10-CM code for supporting medical necessity would need to be reported, which would include the symptoms the patient was feeling and the injury sustained.

Global or Split?

Don't forget the global components of TC and 26 when coding for radiology services. If the provider organization owns the equipment but contracts with an outside radiology group to review and interpret the findings with a report, only TC is reported for the technical component.

If the provider is contracted to review, interpret, and write a report on the image taken by another entity, then onlymodifier 26 is reported.

However, if the provider organization both owns the equipment and the physicians interpret and write the report, then the service is reported globally (without any modifiers).

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

What’s Going on with the COVID Vaccines Now?
May 4th, 2023 - Wyn Staheli
Keeping up with the changes to the COVID vaccines has certainly been a rollercoaster ride and we now have two new twists to this exciting ride. Buckle up and let’s look at how this changes things.
Reporting Modifiers 76 and 77 with Confidence
April 18th, 2023 - Aimee Wilcox
Modifiers are used to indicate that a procedure has been altered by a specific circumstance, so you can imagine how often modifiers are reported when billing medical services. There are modifiers that should only be applied to Evaluation and Management (E/M) service codes and modifiers used only with procedure codes. Modifiers 76 and 77 are used to identify times when either the same provider or a different provider repeated the same service on the same day and misapplication of these modifiers can result in claim denials.
Five Documentation Habits Providers Can Use Implement to Improve Evaluation & Management (E/M) Scoring
April 11th, 2023 - Aimee Wilcox
Provider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.
Second Quarter 2023 Updates are Different This Year
April 6th, 2023 - Wyn Staheli
The second quarter of 2023 is NOT business as usual so it is important to pay attention to ensure that organizational processes and training take place to avoid mistakes. Not only have ICD-10-CM coding updates been added to the usual code set updates (e.g., CPT, HCPCS, ICD-10-PCS), but the end of the COVID-19 Public Health Emergency will bring about changes that will also take place during the quarter (but not on April 1, 2023.
7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth Fraud
March 28th, 2023 - Aimee Wilcox
A recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?
MUEs and Bilateral Indicators
March 23rd, 2023 - Chris Woolstenhulme
MUEs are used by Medicare to help reduce improper payments for Part B claims. This article will address the use of the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) and how they are used by CMS.
It is True the COVID-19 PHE is Expiring
March 16th, 2023 - Raquel Shumway
The COVID-19 PHE is Expiring, according to HHS. What is changing and what is staying the same? Make sure you understand how it will affect your practice and your patients.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association