Pulmonology Coding Alert

Question: Coding Clinic, fourth quarter 1990, page 25, states that postoperative atelectasis documented in a progress note is not reported if it is only an incidental radiographic or physical finding, given that it is self-limited. An outpatient comes in for a chest xray. The only finding is atelectasis. Does the Coding Clinic information apply in this case? I'd appreciate any additional information on the Coding Clinic's instruction.

Florida Subscriber

Answer: Patients are expected to have postoperative atelectasis to some degree, and are given incentive spirometry and other pulmonary exercises to re-expand the lungs after surgery. Most cases resolve on their own, requiring no intervention. Outpatients who have a chest xray which identifies atelectasis are not treated in the same manner. This is considered an abnormal finding which requires further investigation of the cause and/or intervention. In this situation, you would report 518.0 (Pulmonary collapse).