Orthopaedic Imaging Billing: X-Ray, MRI, and Ultrasound Guidance Coding with Modifiers 26 and TC

In orthopaedic imaging billing, the modifier depends on who owns the equipment and who interprets the study. If your practice owns the X-ray or MRI equipment and your physician reads the images, you bill the global code with no modifier. If the study is performed on hospital or facility equipment and your physician interprets it, you bill the professional component with modifier 26. If your practice provides only the equipment, staff, and supplies while someone else interprets, you bill the technical component with modifier TC. Getting this wrong, or failing to document a separate written interpretation, is one of the most common reasons in-office imaging revenue goes uncollected or gets taken back in audits.

This guide covers the global, professional, and technical split, the X-ray, MRI, and ultrasound codes orthopaedic practices use most, and the documentation and payment rules that affect reimbursement.

Why imaging billing matters for orthopaedic practices

Imaging is part of almost every orthopaedic encounter. New patient visits for joint pain, fracture follow-ups, post-operative checks, and injection visits all generate X-rays, and many practices also perform MRI and diagnostic ultrasound in-house. Because the volume is so high, small coding errors compound quickly: an X-ray series billed at the wrong number of views, a professional component missed on a hospital study, or an interpretation that is never documented as a separate report can add up to significant lost revenue per surgeon per year.

Imaging also intersects with E&M coding. How you bill an X-ray affects how you can count it toward medical decision making, which in turn affects the E&M level you can support.

Global, professional component, and technical component

Most diagnostic imaging CPT codes have two parts:

• Technical component (TC): the equipment, the technologist, the supplies, and the facility costs of performing the study.
• Professional component (26): the physician's interpretation and written report.

How you bill depends on the setting:

• Global (no modifier): your practice owns the equipment, your staff performs the study, and your physician interprets it. You bill the full code once.
• Modifier 26: your physician interprets a study performed on equipment owned by a hospital, ASC, or another entity that bills the technical component. This is common for surgeons who read images taken in a hospital outpatient department or emergency department.
• Modifier TC: your practice performs the study but another physician, such as a contracted radiologist, interprets it and bills the professional component.

A frequent error in hospital-employed or hybrid practices is billing the global code for studies performed on hospital equipment. The hospital bills the technical component on its facility claim, so the payer sees a duplicate technical charge and denies or recoups.

Documentation: the interpretation must be a separate report

To bill the professional component, whether globally or with modifier 26, the physician must document an interpretation and report. Medicare's guidance in the Claims Processing Manual treats the interpretation as a distinct service with a written report. A brief statement in the visit note such as "X-rays reviewed, no fracture" generally does not support separate payment for the interpretation.

A defensible orthopaedic imaging report includes:

• The study performed, including the body part, laterality, and number and type of views.
• The clinical indication.
• Findings.
• An impression.
• The interpreting physician's signature and date.

Many EHRs let surgeons create the report as a discrete document or a clearly labeled section of the note. Either approach works as long as the report stands on its own.

Imaging and E&M: avoiding double counting

Under the AMA's E&M guidelines for office visits, the ordering and review of tests counts toward the data element of medical decision making. However, when the physician separately reports the interpretation of a test, that test cannot also be counted as ordered or reviewed for E&M purposes. In other words, if you bill 73562 for a knee X-ray your practice performed and you interpreted, you do not also get E&M data credit for ordering or reviewing that X-ray.

The opposite applies to outside studies. Independent interpretation of a test performed by another physician or qualified health care professional, and not separately reported, counts in the data element. When a patient brings in an outside MRI and the surgeon personally reviews the images and documents their own interpretation, that work supports the E&M level even though it is not separately billed. Document it explicitly, because surgeons do this constantly and rarely get credit for it.

Common orthopaedic X-ray codes

X-ray codes are defined by body part and number of views. Billing a three-view code when only two views were taken is an overpayment, and billing a two-view code when four were taken leaves revenue on the table. Commonly used codes include:

• Shoulder: 73020 (one view), 73030 (minimum of two views).
• Knee: 73560 (one or two views), 73562 (three views), 73564 (complete, four or more views), 73565 (both knees, standing, anteroposterior).
• Hip, unilateral, with pelvis when performed: 73501 (one view), 73502 (two or three views), 73503 (minimum of four views).
• Wrist: 73100 (two views), 73110 (complete, minimum of three views).
• Hand: 73120 (two views), 73130 (minimum of three views).
• Ankle: 73600 (two views), 73610 (complete, minimum of three views).
• Foot: 73620 (two views), 73630 (complete, minimum of three views).
• Lumbar spine: 72100 (two or three views), 72110 (minimum of four views).
• Cervical spine: 72040 (two or three views), 72050 (four or five views), 72052 (six or more views).

Make sure the order, the technologist's record, and the report all list the same number of views. Discrepancies are a common audit finding.

For bilateral studies, follow payer instructions. Many payers want each side reported on its own line with RT and LT. Some codes, like 73565, already describe both sides and should be reported once.

Payment reductions to know

Film and computed radiography

Medicare reduces the technical component payment for X-rays taken with film (modifier FX, a 20% reduction) and with computed radiography (modifier FY, a 10% reduction since 2023). Practices that have not fully transitioned to digital radiography should report these modifiers when required, and should factor the reduction into equipment replacement decisions.

Multiple procedure payment reduction for advanced imaging

Medicare applies a multiple procedure payment reduction (MPPR) to certain advanced imaging (CT, MRI, and ultrasound) when more than one study is performed on the same patient in the same session. The technical component of each additional study is reduced by 50%, and the professional component of each additional study is reduced by 5% when the same physician interprets them. Plain X-rays are not subject to this imaging MPPR. Commercial payers often have their own versions of this policy, so check payer reimbursement policies.

MRI in the orthopaedic practice

Practices with in-office MRI most often bill these codes:

• Upper extremity joint: 73221 (without contrast), 73222 (with contrast), 73223 (without and then with contrast).
• Lower extremity joint: 73721 (without contrast), 73722 (with contrast), 73723 (without and then with contrast).
• Spine: 72141 (cervical, without contrast) and 72148 (lumbar, without contrast), among others.

MRI is a prior authorization target for most commercial and Medicare Advantage payers, often through radiology benefit managers. Match the authorized CPT code exactly, including contrast status. An authorization for 73721 does not cover 73723 if the radiologist decides to add contrast.

Practices that own MRI equipment and refer patients to it must also comply with the Stark Law in-office ancillary services exception. Under the Affordable Care Act, physicians who refer Medicare patients for in-office MRI, CT, or PET must give patients written notice that they can obtain the service elsewhere, along with a list of alternative suppliers in the area.

Diagnostic ultrasound and ultrasound guidance

Diagnostic musculoskeletal ultrasound uses 76881 for a complete joint evaluation and 76882 for a limited joint or focal evaluation. A complete study requires evaluation of the joint and its associated muscles, tendons, and soft tissue, with permanently recorded images. If the documentation supports only a focused look at one structure, use 76882.

Ultrasound guidance for injections is handled differently. Joint injection codes 20604, 20606, and 20611 include ultrasound guidance with permanent recording and reporting, so 76942 should not be billed with them. When an injection is performed without ultrasound guidance, use 20600, 20605, or 20610. If ultrasound is used but images are not permanently recorded and reported, the guided code is not supported.

The most common orthopaedic imaging billing errors

1. Billing the global code for studies performed on hospital equipment.
2. Billing an interpretation without a separate signed report.
3. Billing more views than were performed, or fewer than were documented.
4. Counting a separately billed X-ray toward E&M data.
5. Failing to document independent interpretation of outside images.
6. Billing 76942 with guided injection codes.
7. Mismatching an MRI authorization and the CPT code actually performed.
8. Missing FX or FY modifiers on film or computed radiography studies.

How AI coding supports imaging accuracy

Imaging errors are easy to make because they require coordinating the order, the technologist's record, the report, the place of service, and the E&M note. Maia's E&M AutoCoder and Surgical AutoCoder read the documentation inside the EHR and recommend CPT and ICD-10 codes, modifiers, and clinical justification before a human coder reviews the chart, including credit for independent interpretation when the surgeon documents it. Orthopaedic groups use Maia across Athena, eClinicalWorks, and coming soon, Epic, ModMed, NextGen, and Tebra.

Frequently asked questions

When should an orthopaedic surgeon use modifier 26?

Use modifier 26 when the surgeon interprets and reports an imaging study performed on equipment owned by another entity, such as a hospital, that bills the technical component. Do not use modifier 26 for studies performed on your own practice's equipment if your physician also interprets them. Those are billed globally.

What is the difference between modifier 26 and modifier TC?

Modifier 26 reports only the professional component: the physician's interpretation and written report. Modifier TC reports only the technical component: the equipment, staff, and supplies used to perform the study.

Can I bill an X-ray interpretation and count it toward the E&M level?

No. Under AMA E&M guidelines, a test that the physician separately reports cannot also be counted as ordered or reviewed in the data element of medical decision making.

Can I bill for reviewing an outside MRI?

Generally you cannot bill a separate interpretation for a study that has already been interpreted and billed by another physician. However, if your surgeon personally reviews the images and documents an independent interpretation, it counts toward the data element of medical decision making for the E&M visit.

Can 76942 be billed with a joint injection?

Not with 20604, 20606, or 20611, which already include ultrasound guidance. Those codes require permanent recording and reporting of the ultrasound images.

Does Medicare reduce payment for film X-rays?

Yes. Medicare reduces the technical component by 20% for film X-rays (modifier FX) and by 10% for computed radiography (modifier FY).

The bottom line

In-office imaging is a significant source of orthopaedic revenue, and most of the leakage comes from a handful of predictable errors: the wrong component, a missing report, mismatched views, and lost E&M credit. A clear documentation standard and a coding workflow that checks each study against the setting and the report will recover most of it.

See how Maia's AutoCoder handles this automatically for orthopaedic practices. Book a demo at usemaia.com.