Pulmonology Coding Alert

Question: A patient underwent two-view chest x-ray after going to the pulmonologist with complaints of wheezing, coughing, and trouble catching her breath. The ordering physician documented focal rhonchi and ordered the x-ray to check for acute bronchitis or pneumonia. The chest x-ray results revealed bronchitis. How should I code this case?

Alaska Subscriber

Answer: For the x-ray, you should report 71020 (Radiologic examination, chest, 2 views, frontal and lateral). Link 71020 to the appropriate bronchitis code, based on your documentation: 466.0 (Acute bronchitis).

To further support the chest x-ray, you should report the signs and symptoms as secondary diagnoses. For example, you may report 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) for the rhonchi, which are snore-like sounds caused by the narrowed airway.