Pulmonology Coding Alert

Question: I have a report from a pulmonologist in our practice following an encounter with a patient. The patient presented with a nagging cough for several weeks, sputum production, shortness of breath (SOB), wheezing, and fatigue. The pulmonologist performed a physical exam and ordered chest X-rays (CXR). The CXR was performed in the office and captured anteroposterior (AP) and lateral views of the patient’s chest. After reviewing the results, the physician diagnosed the patient with acute bronchitis with bronchospasm.

What codes do I need to report?

Codify Subscriber

Answer: In addition to the appropriate evaluation and management (E/M) code, you’ll need one CPT^® code and one ICD-10-CM code.

For the CPT^® code, you’ll assign 71046 (Radiologic examination, chest; 2 views) to report the AP and lateral chest X-ray views.

Next, you’ll turn your attention to the diagnosis code. You indicated the physician diagnosed the patient with acute bronchitis with bronchospasm. For this code, you’ll assign J20.9 (Acute bronchitis, unspecified). Symptoms of acute bronchitis include cough, production of mucus, fatigue, SOB, fever and chills, and chest discomfort.

Several acute bronchitis codes include a condition that’s causing the bronchitis. Based on the information you’ve provided, you’re best off choosing J20.9 since the code descriptor doesn’t specify a causal relationship. Additionally, parent code J20.- (Acute bronchitis) features an Includes note that lists “acute and subacute bronchitis (with) bronchospasm.” If the physician could not confirm the underlying condition, you would only report the patient’s symptoms as the dx code.