Primary Care Coding Alert

Question: A 38-year-old established patient reports to the FP with complaints of wheezing, coughing and trouble catching her breath. After the non-physician practitioner (NPP) performs a problem focused history, the FP performs an expanded problem focused exam and discovers focal rhonchi. The FP orders a two-view chest x-ray to check for upper respiratory infection (URI). The chest x-ray results reveal acute URI, and the rhonchi clears up upon reevaluation. We own the x-ray equipment, and the overall notes indicate a level-three-E/M. How should I code this scenario? Kansas Subscriber Answer: You'll submit a pair of CPT codes, a pair of ICD-9 codes, and a modifier to make this coding correct. On the claim, report the following: 71020 (Radiologic examination, chest, 2 views, frontal and lateral;) for the x-ray 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these [...]