Radiology Coding Alert

Question: A patient presented to our radiology clinic with complaints of shortness of breath, persistent cough, and coughing up blood. The radiologist captured a two-view chest X-ray and reported a suspicious finding. After interpreting the chest X-ray, the radiologist performed a two-view sternum X-ray. The provider interpreted the sternum images and reported the results as a mass in the patient’s right lung.

Aren’t sternum and chest X-rays the same thing?

Michigan Subscriber

Answer: No, sternum and chest X-rays are not the same thing. Under the X-ray section of the CPT^® code set Index, you’ll find separate entries for “chest” and “sternum.” For your situation, you’ll assign 71046 (Radiologic examination, chest; 2 views) to report the two-view chest X-ray and 71120 (Radiologic examination; sternum, minimum of 2 views) for the two-view sternum X-ray.

The sternum is a T-shaped, flat bone in the center of your chest that forms part of the ribcage. In addition to protecting some internal organs, the sternum connects the ribs and the clavicle to your skeletal system.

Important: Make sure the provider has documented the medical necessity to perform the sternum X-ray after the chest X-ray. “One condition that comes to mind would be a suspicious finding on a chest X-ray that could warrant a provider ordering an X-ray of the sternum,” says Chelsea Kemp, RHIA, CCS, COC, CPC, CPCO, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC Approved Instructor, outpatient coding educator/auditor at Yale New Haven Health in New Haven, Connecticut.

To document the reason for the visit, you’ll turn to the ICD-10-CM code set. The radiologist documented a mass of the patient’s right lung. In the ICD-10-CM Alphabetic Index, look for Mass > lung, which directs you to R91.8 (Other nonspecific abnormal finding of lung field). When you verify the code in the Tabular List, you’ll find the code features “Lung mass NOS found on diagnostic imaging of lung” as an additional synonym. This code represents the radiologist’s findings listed in their report, so you can assign R91.8 as the diagnosis code.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC