Ask Your Provider for Additional Information When It’s Needed
Question: An 80-year-old patient presented complaining of a cough lasting for more than a month, fatigue, and weight loss. The pulmonologist ordered a high-resolution CT scan of the patient’s chest. The findings revealed fibrotic changes in the patient’s lungs. The pulmonologist diagnosed the patient with pulmonary fibrosis and prescribed antifibrotic drugs. How do I report this encounter? Kentucky Subscriber Answer: Your situation requires further querying of the provider before you can nail down the correct codes for reimbursement. Let’s start with the diagnosis. Use J84.10 (Pulmonary fibrosis, unspecified) to report the pulmonary fibrosis diagnosis. The ICD-10-CM code book lists several conditions that you can report with J84.10, such as: However, if the documentation mentions a specific type of pulmonary fibrosis, then use that information to select your code. For example, assign J84.112 (Idiopathic pulmonary fibrosis) if the physician documented an idiopathic pulmonary fibrosis diagnosis. Next, open the CPT® code book and locate the CT scans of the thorax codes listed under 71250-71270. Assign 71250 (Computed tomography, thorax, diagnostic; without contrast material) to report the CT scan without contrast of the patient’s chest. Use 71260 (… with contrast material(s)) if the physician ordered the CT with contrast material. Or you’ll assign 71270 (… without contrast material, followed by contrast material(s) and further sections) if the provider captured CT images of the chest without contrast, then administered contrast and captured additional images. Code 71270 allows the provider to compare the two sets of images. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
