Bilateral Radiography Billed With Unilateral Code on UB 04 form

This is an example only.  Please adapt to your billing situation.

In this case a clinic physician orders an eye socket X-ray, which is performed at and billed by the clinic.  This claim example illustrates the billing of a bilateral radiographic procedure with a unilateral code.

Enter the two-digit facility type code “73” (clinic – free standing) and one-character claim frequency code “1” as “731” in the Type of Bill field (Box 4).

CPT-4 code 70190 (radiologic examination; optic foramina) is billed with modifier TC (technical component) in the HCPCS/Rates field (Box 44).  Enter a description of the service (eye socket X-ray) in the Description field (Box 43).  The description is optional but aids in claim adjudication and provider record keeping.

Enter the date of service, June 7, 2007, in six-digit format as 060707
in the Service Date field (Box 45).  Enter a “2” in the Service Units field (Box 46).  This number indicates the procedure is bilateral.  Enter the usual and customary charges in the Total Charges field (Box 47). 
Enter Code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in TOTALS (Box 47, line 23).

Enter “O/P Medi-Cal” to indicate the type of claim and payer in the Payer Name field (Box 50).  The community clinic’s provider number is placed in the NPI field (Box 56).

Enter the NPI for the referring or prescribing physician in the Attending field (Box 76).  This field is mandatory for radiologists.  Enter the NPI for the rendering provider in the first Operating field (Box 77).

Enter in the Remarks field (Box 80) that the procedure was performed
bilaterally.