Radiology Coding Alert

Question: I have a radiology report that states the radiologist captured “PA chest, AP, RL, and RAO X-ray views” to evaluate the patient’s right ribcage for a possible fracture following a car accident. After reviewing the images, the provider documented the patient experienced three right rib fractures.

What codes should I assign for this encounter?

South Dakota Subscriber

Answer: You will need one CPT^® code, one modifier, and one ICD-10-CM code to report this encounter.

For the procedure, assign 71101 (Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views) to report the X-rays of the patient’s right ribcage. You state in your question that the radiologist captured anteroposterior (AP), right lateral (RL), and right-angle oblique (RAO) rib views as well as a posteroanterior (PA) view of the chest. The documented views meet 71101’s descriptor requirements.

You’ll also append modifier RT (Right side) to 71101 to show that the provider performed the procedure on the right side of the patient’s body.

Next, you’ll assign S22.41XA (Multiple fractures of ribs, right side, initial encounter for closed fracture) to report the three right rib fractures. According to the ICD-10-CM Official Guidelines, I.C.19.c, “A fracture not indicated as open or closed should be coded to closed.”

Under parent code S22.- (Fracture of rib(s), sternum and thoracic spine), the 7th character “A” is used for an initial encounter for a closed fracture and 7th character “B” is designated for an initial encounter for an open fracture. You didn’t mention if the fractures were open or closed in your question, which is why 7th character A would be the correct choice under these circumstances.

Of course, double-check the report to see if the fractures are noted as open or closed. If the provider does note the fractures are open, then you’ll use S22.41XB (Multiple fractures of ribs, right side, initial encounter for open fracture).