Radiology Coding Alert

Question:

A woman who fell on her unprotected side reports to the ED. The ED physician notes that the patient had "the beginnings of a contusion to her right abdominal wall upon reporting." During the examination, she reports shortness of breath and says the pain is a 6 on a scale of 10. To rule out broken ribs, the physician orders a rib X-ray, and I'm coding for interpretation of that X-ray. The X-rays reveal no broken bones, so final diagnosis is abdominal wall contusion. What is the proper code for the X-ray?

Kentucky Subscriber

Answer:

The proper code depends on the type of X-ray the ED physician ordered and the radiologist performed, so you'll need to check the orders and the X-ray documentation. There are four different CPT^® codes for rib X-rays:

71100 -- Radiologic examination, ribs, unilateral; 2 views

71101 -- ... including posteroanterior chest, minimum of 3 views

71110 -- Radiologic examination, ribs, bilateral; 3 views

71111 -- ... including posteroanterior chest, minimum of 4 views.

So, for instance, if documentation shows the patient had a unilateral two-view rib X-ray, on the claim you may include the following:

71100 for the X-ray

Modifier 26 (Professional component) appended to 71100 to show that you are only coding for the physician's interpretation of the X-ray

922.2 (Contusion of trunk; abdominal wall) linked to 71100 to represent the patient's injured abdomen

786.05 (Shortness of breath) linked to 71100 to represent the patient's shortness of breath.