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A radiologic examination of the ankle, designated by CPT® Code 73610, involves a comprehensive imaging study that captures the bones of the distal lower extremities, specifically the tibia, fibula, and talus. This procedure utilizes X-ray imaging, which employs indirect ionizing radiation to create detailed pictures of the internal structures of the body. The principle behind X-ray imaging is based on the varying densities and compositions of human tissues; as X-rays pass through the body, some are absorbed while others penetrate and are captured on a detector, resulting in a two-dimensional representation of the anatomical structures. This examination is typically performed to investigate various clinical concerns, including pain, limping, or swelling in the ankle region. It is also instrumental in diagnosing conditions such as fractures, dislocations, deformities, degenerative diseases, osteomyelitis, arthritis, foreign bodies, and the presence of cysts or tumors. Furthermore, ankle X-rays are essential in assessing the alignment of lower extremity bones post-fracture treatment. The standard views included in this complete examination are the anteroposterior (AP) view, which captures the ankle from front to back, the lateral view that shows the side profile, the oblique view taken with the body and leg partially rotated, and a stress study that involves applying manual traction to the joint. For procedures requiring fewer views, CPT® Code 73600 is applicable, which covers an X-ray examination of the ankle with only two views.
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The radiologic examination of the ankle, coded as CPT® 73610, is indicated for a variety of clinical scenarios. These include:
The procedure for a complete radiologic examination of the ankle, as described by CPT® Code 73610, involves several key steps to ensure comprehensive imaging. The first step is patient positioning, where the patient is typically seated or lying down in a manner that allows for optimal access to the ankle. The technician will then prepare the X-ray machine and ensure that the appropriate settings are configured for the examination. Following this, a minimum of three standard views of the ankle will be obtained. The first view is the anteroposterior (AP) view, which captures the ankle from front to back, providing a clear image of the joint and surrounding structures. The second view is the lateral view, which shows the side profile of the ankle, allowing for assessment of the alignment and any potential fractures. The third view is the oblique view, taken with the leg partially rotated, which offers additional perspective on the ankle's anatomy. In some cases, a stress study may also be performed, where manual traction is applied to the joint to evaluate its stability and alignment under stress. Throughout the procedure, the technician will ensure that the patient remains still to obtain clear images, and protective measures, such as lead aprons, may be used to shield other parts of the body from radiation exposure. Once the images are captured, they will be reviewed for quality and clarity before being processed for interpretation by a radiologist or physician.
After the completion of the radiologic examination of the ankle, patients may be advised to resume normal activities unless otherwise directed by their healthcare provider. The images obtained will be analyzed by a radiologist, who will provide a report detailing any findings related to fractures, dislocations, or other abnormalities. This report will be shared with the referring physician, who will discuss the results with the patient and determine the appropriate course of action based on the findings. In some cases, further imaging or follow-up examinations may be necessary to monitor the condition or assess the effectiveness of treatment. Patients should be informed about any potential side effects from the radiation exposure, although the levels used in standard X-ray procedures are generally considered safe. Additionally, if any immediate concerns arise post-procedure, such as increased pain or swelling, patients should contact their healthcare provider for further evaluation.
| Short Descr | X-RAY EXAM OF ANKLE | Medium Descr | RADEX ANKLE COMPLETE MINIMUM 3 VIEWS | Long Descr | Radiologic examination, ankle; complete, minimum of 3 views | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 1 - Diagnostic Tests for Radiology Services | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 3 - The usual payment adjustment for bilateral procedures does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | STV-Packaged Codes | ASC Payment Indicator | Packaged service/item; no separate payment made. | Type of Service (TOS) | 4 - Diagnostic Radiology | Berenson-Eggers TOS (BETOS) | I1B - Standard imaging - musculoskeletal | MUE | 3 | CCS Clinical Classification | 226 - Other diagnostic radiology and related techniques |
| RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | TC | Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | FY | X-ray taken using computed radiography technology/cassette-based imaging | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | FX | X-ray taken using film | GW | Service not related to the hospice patient's terminal condition | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | KX | Requirements specified in the medical policy have been met | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 56 | Preoperative management only: when 1 physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | 99 | Multiple modifiers: under certain circumstances 2 or more modifiers may be necessary to completely delineate a service. in such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. | A5 | Dressing for five wounds | AG | Primary physician | AK | Non participating physician | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CG | Policy criteria applied | ER | Items and services furnished by a provider-based, off-campus emergency department | F8 | Right hand, fourth digit | FT | Unrelated evaluation and management (e/m) visit on the same day as another e/m visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (report when an e/m visit is furnished within the global period but is unrelated, or when one or more additional e/m visits furnished on the same day are unrelated) | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | JZ | Zero drug amount discarded/not administered to any patient | KT | Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item | MA | Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition | MC | Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues | MH | Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider | PA | Surgical or other invasive procedure on wrong body part | PC | Wrong surgery or other invasive procedure on patient | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | Q8 | Two class b findings | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | SA | Nurse practitioner rendering service in collaboration with a physician | ST | Related to trauma or injury | T1 | Left foot, second digit | T3 | Left foot, fourth digit | T5 | Right foot, great toe | T8 | Right foot, fourth digit | T9 | Right foot, fifth digit | TA | Left foot, great toe | TL | Early intervention/individualized family service plan (ifsp) | TT | Individualized service provided to more than one patient in same setting | U6 | Medicaid level of care 6, as defined by each state | UD | Medicaid level of care 13, as defined by each state | UH | Services provided in the evening | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2009-01-01 | Changed | Code description changed |
| Pre-1990 | Added | Code added. |
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