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Question: A 66-year-old established patient presented for an evaluation of recurrent lower respiratory infections, having experienced three bouts of pneumonia in the past year. The patient attested to a daily productive cough with thick sputum, shortness of breath on exertion, and fatigue. The pulmonologist performed a physical examination, collected a blood sample for immunoglobulins G, A, and M (IgG, IgA, and IgM) testing, and ordered a CT with contrast. After reviewing the images, the physician diagnosed the patient with cylindrical bronchiectasis in the right lower lobe (RLL) with bronchial wall thickening.

What codes do we report for the encounter?

Nebraska Subscriber

Answer: Use 71260 (Computed tomography, thorax, diagnostic; with contrast material(s)) to report the CT of the chest with contrast material. You’ll also assign 3 units of 82784 (Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each) to report the three different immunoglobulins tested.

For the diagnosis, you’ll need two codes. Use J47.9 (Bronchiectasis, uncomplicated) to report the RLL cylindrical bronchiectasis. You’ll also assign Z87.01 (Personal history of pneumonia (recurrent)) for the patient’s history of pneumonia. The documentation showed that the patient experienced three episodes of pneumonia in the previous 12 months, which means the condition is recurrent, even if the patient isn’t currently experiencing the condition.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC