Report an Abnormality Without a Pathology Report
Question: A 47-year-old patient presented to our pulmonology practice with a chronic cough and blood in their sputum. After capturing a history and performing a physical examination, the pulmonologist ordered posteroanterior (PA) and lateral X-rays of the patient’s chest. After reviewing the images and finding a shadow in the left lung, the pulmonologist ordered a chest CT scan with contrast. The CT scan confirmed the presence of a nodule in the left lung. The physician referred the patient to a thoracic surgeon for a possible biopsy. What codes will I report for this encounter? California Subscriber Answer: Let’s start with the ICD-10-CM codes. This situation is tricky as there isn’t a pathology report for the abnormality. In this case, you’ll use R91.1 (Solitary pulmonary nodule) to report the documented left lung nodule. Next, you’ll turn to the CPT® code book. In addition to the appropriate evaluation and management (E/M) code, you’ll need two procedure codes for the X-rays and CT scan. Use 71046 (Radiologic examination, chest; 2 views) to report the PA and lateral chest X-ray views. You’ll then assign 71260 (Computed tomography, thorax, diagnostic; with contrast material(s)) to report the CT scan of the patient’s chest with contrast material. Important: Double-check the documentation to ensure the contrast material was administered intravascularly, intra-articularly, or intrathecally. You can report “with contrast” imaging procedures only if the contrast is administered using the methods mentioned, per the CPT® guidelines. If the provider administered the contrast material by any other method, you’ll use 71250 (Computed tomography, thorax, diagnostic; without contrast material). Mike Shaughnessy, BA, CPC, Production Editor, AAPC
