ICD 10 Coding Alert

Question: A patient visited our emergency department (ED) with complaints of coughing up blood, difficulty breathing when lying down, and wheezing sounds while breathing. Pulmonary was consulted. The pulmonologist captured a history, performed a physical examination, and ordered a sputum culture, a CBC, a CMP, and a two-view chest X-ray. After reviewing the path/lab results and informally reviewing the X-ray images, the physician had enough information to diagnose the patient with acute edema of the left lung. The pulmonologist discussed the management options with the ED physician and the pulmonologist ultimately recommended admission, which occurred the same calendar day.

What codes should I assign for this encounter?

Pennsylvania Subscriber

Answer: You’ll assign one CPT^® code and one ICD-10-CM code to report this encounter. You should begin by assigning 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.) since the patient was ultimately admitted to the hospital by the pulmonologist. The patient presented to the ED with an acute illness or injury that poses a threat to life or bodily function and the physician ordered and admitted the patient to the hospital, which meet the requirements for a high level of medical decision making (MDM).

You should not assign 71046 (Radiologic examination, chest; 2 views) to report the chest X-ray interpretation, since the pulmonologist did not perform the official interpretation (this is typically provided by radiology for ED patients). However, the “wet read” counts toward the complexity of data (Category 2). The management discussion with the ED physician counts toward Category 3. Ordering three tests also counts for Category 1 data, lending to high-complexity data.

Turning to the ICD-10-CM code set, you’ll assign J81.0 (Acute pulmonary edema) to report the patient’s diagnosis. You mentioned the physician documented an acute edema of the lung, which is a synonym listed under the code descriptor.