Radiology Coding Alert

Question: A patient was referred to our radiology facility for chest X-rays after presenting to their general practitioner (GP) with complaints of a persistent cough, coughing up blood, and shortness of breath. The radiologist performed a two-view chest X-ray, and the report showed a suspicious finding. The radiologist then captured a two-view X-ray of the patient’s sternum and then interpreted and reported the results as a mass of the patient’s left lung.

Can we report the chest and sternum X-rays together?

Tennessee Subscriber

Answer: Yes, you can report the chest and sternum X-rays together on the same report. In the situation you present, you’ll assign 71046 (Radiologic examination, chest; 2 views) for the two-view chest X-ray and 71120 (Radiologic examination; sternum, minimum of 2 views) for the two-view sternum X-ray.

The radiologist’s report following the chest X-rays showed the medical necessity to perform the sternum X-ray. “One condition that comes to mind would be a suspicious finding on a chest X-ray that could warrant a provider ordering an X-ray of the sternum,” says Chelsea Kemp, BS, RHIT, CCS, COC, CPC, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC Approved Instructor, outpatient coding educator/auditor at Yale New Haven Health in New Haven, Connecticut.

To locate the chest X-ray code, turn to the AMA’s CPT^® index where you’ll find the range of codes under X-ray > Chest. You’ll then verify the code in the Radiology section in the CPT^® code set. Next, return to the index to locate X-ray > Sternum to find the range of codes. The Radiology chapter in the CPT^® code set lists two other codes in the Chest subsection related to X-rays captured of the patient’s sternum and sternoclavicular joint(s).

You’ll then need to document the reason for the visit. In this case, the radiologist documented a mass of the patient’s left lung. In the ICD-10-CM Alphabetic Index, look for Mass > lung, which directs you to R91.8 (Other nonspecific abnormal finding of lung field). When you verify the code in the tabular list, you’ll find the code features “Lung mass NOS found on diagnostic imaging of lung” as an additional synonym. This code represents the radiologist’s findings listed in their report, so you can assign R91.8 as the diagnosis code.