Radiology Coding Alert

Question: I’m new to radiology coding, and I have a procedure note from a recent encounter. A patient visited our radiology practice for a follow-up single-view chest X-ray after heart surgery. The physician documented that they performed an anteroposterior (AP) chest X-ray, and the patient status as “post-op cardiac patient.” The radiologist also interpreted the results and prepared a written report.

Could you explain what codes to assign for this encounter?

Maine Subscriber

Answer: Starting with the procedure, you’ll assign 71045 (Radiologic examination, chest; single view) to report the single-view chest X-ray. You don’t need to append modifier 26 (Professional component) or TC (Technical component …) since the radiologist performed both components of the procedure.

Next, you’ll turn to the ICD-10-CM code set to locate the appropriate diagnosis code for the encounter. You’ll assign Z48.812 (Encounter for surgical aftercare following surgery on the circulatory system) to indicate the provider performed the X-ray procedure for a patient who recently underwent cardiac surgery.

According to the ICD-10-CM Official Guidelines, Section I.C.21.c.7, “Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.” The guidelines continue to instruct that aftercare codes are typically listed as the first diagnosis code “to explain the specific reason for the encounter,” in this case, for a post-op examination of the surgical space.