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 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to
• 99213 to show that the E/M and x-ray were separate services
• 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99213 to represent the patient's URI
• 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99213 as a secondary diagnosis to represent the patient's focal rhonchi.

Secondary Dx decoded: Even though the focal rhonchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient's condition, and can only strengthen your medical necessity case for the chest-x-ray.