Radiology Coding Alert

Question: A mother brings in an infant for a two-view chest and abdomen X-ray. The indicating diagnosis states “possible ingested foreign body.” Do we use the same CPT® codes as we would for an adult? Also, is a screening code appropriate here?

South Carolina Subscriber

Answer: In the case of an infant, a physician will not generally perform two separate X-rays to examine the abdomen and chest. This lacks practicality from the perspective that a traditional chest X-ray will cover both anatomical areas. Additionally, physicians want to limit the degree of radiation exposure as much as possible when working on children. Unless there is clear evidence that the physician has performed two separate examinations, then the correct CPT^® code to apply here is 71020 (Radiologic examination, chest, 2 views, frontal and lateral).

Deciding on the indicating diagnosis is where this scenario becomes tricky. When it comes to diagnosis coding, there are a few key terms that should raise an immediate red flag. One of these terms revolves around the use of the word “possible.” If a situation arises where the only applicable diagnosis contains the use of “possible” or “likely,” the coder should send the report back to the provider for clarification.

The only exception to this rule comes when you report these keywords alongside a term synonymous with screening. For instance, if the diagnosis stated “screening for possible foreign body,” then the coder could confidently apply screening code Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out) as a primary diagnosis.

Caveat: While you can use Z03.89 as a primary diagnosis, this is not true for all screening codes. For instance, you cannot apply Z13.89 (Encounter for screening for other disorder) as a primary diagnosis.

As for this particular example, the coder would want to refer back to the physician for a valid diagnosis – or additional clarification as to whether or not this was, in fact, a screening procedure.