Identify a Solitary Pulmonary Nodule Code for This Chest CT Case
Question: A new senior patient presented to the pulmonology practice after an opacity in the middle of the right lung was noted on a screening X-ray. The patient is a former smoker with no cough, hemoptysis, weight loss, or dyspnea. The pulmonologist ordered a CT scan of the thorax without contrast material, which was performed and interpreted in house. The lungs, pleura, mediastinum, hila, and upper abdomen were visualized. The findings list a single 8 mm smooth-margined solid nodule in the right upper lobe with no spiculation, cavitation, associated adenopathy, or effusion. How do we report this encounter? Georgia Subscriber Answer: Let’s start by reporting the procedure that was performed during the encounter — the CT scan of the thorax without contrast material. Assign 71250 (Computed tomography, thorax, diagnostic; without contrast material) to report this imaging examination. You don’t need any modifiers appended to the code since the practice owns the equipment and an employee of the practice interpreted the images. Next, use R91.1 (Solitary pulmonary nodule) to report what was found during the imaging exam. You’ll also need to report a code to identify the patient’s history as a smoker. Assign Z87.891 (Personal history of nicotine dependence) to indicate the patient previously had an addiction to nicotine but isn’t dependent on the substance any longer. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
