Radiology Coding Alert

Question: After a level-four office evaluation and management (E/M) service for an established patient, the surgeon orders a four-view bilateral rib X-ray with posteroanterior (PA) chest view. They then perform open treatment on two rib fractures on the right side, and a single rib on the left side.

How should I code this encounter for the radiologist?

Colorado Subscriber

Answer: This encounter requires several codes to complete the claim, but if you’re billing for only the radiologist’s portion, you’ll need one CPT® code and two ICD-10-CM codes.

Starting with the X-rays, you’ll assign 71111 (Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views) to report the radiologist’s services. You will not need any modifiers to indicate laterality since 71111’s descriptor includes bilateral views. However, make sure the documentation and images match the requirements for four views, which includes a PA chest view.

Next, you’ll turn to the ICD-10-CM code set to assign the diagnosis codes. The patient underwent the X-rays where the radiologist confirmed the rib fractures. You’ll assign S22.41XA (Multiple fractures of ribs, right side, initial encounter for closed fracture) to represent the patient’s right-side rib fractures and S22.32XA (Fracture of one rib, left side, initial encounter for closed fracture) to represent the left-side rib fracture.