Radiology Coding Alert

Question: On a computed tomography (CT) scan of the chest for a patient with respiratory distress, the radiologist documents bilateral ground glass opacities and pulmonary consolidation and suspects a COVID-19 diagnosis. In the impression, the radiologist recommends a test to rule out a COVID-19 diagnosis. How should I sequence the diagnoses? Also, should modifier CS be appended to 71250?

Wyoming Subscriber

Answer: The dictation report indicates that the radiologist “suspects” a COVID-19 diagnosis. The terminology here may be confusing when you check the most recent ICD-10-CM guidelines on COVID-19 diagnosis sequencing and reporting. The guidelines only advise that you report code Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases) if the patient has a known or suspected exposure to COVID-19. Unless the indication or impression of the dictation report elaborates further, you don’t have enough information to report Z20.828.

While no specific guidelines exist on coding a suspected COVID-19 diagnosis based on clinical findings, you can refer back to the guidelines advising that you code signs and symptoms for “probable, suspected, etc.” diagnoses. In this example, you will report ICD-10-CM codes R91.8 (Other nonspecific abnormal finding of lung field) and R06.03 (Acute respiratory distress). If the provider conclusively links the respiratory distress to the ground glass opacities, you may omit R06.03 as an included diagnosis code.

Lastly, you will not append modifier CS (Cost-sharing for specified covid-19 testing-related services that result in an order for or administration of a covid-19 test) to code 71250 (Computed tomography, thorax; without contrast material). Modifier CS is exclusively reserved for evaluation and management (E/M) visit codes. If the treating provider who requested the imaging proceeds to order COVID-19 testing via a telehealth E/M visit with the patient, they may append modifier CS to the E/M code.