Revenue Cycle Insider

Question: A 75-year-old new patient presented to the pulmonologist with chronic cough, fatigue, and weight loss. The physician collected the patient’s history and performed a physical examination, after which they ordered a CT scan of the chest. The CT scan revealed fibrotic changes in the lungs. The provider diagnosed the patient with idiopathic pulmonary fibrosis and prescribed antibiotics.

Can you help me report this encounter?

Washington Subscriber

Answer: Certainly! Let’s start with the evaluation and management (E/M) visit code. The patient presented with an undiagnosed new problem, which meets the moderate level of medical decision making (MDM). Next, the provider ordered a CT scan of the chest and reviewed the results. This falls under the low level of MDM. Lastly, the physician prescribed antibiotics to the patient, which corresponds with a moderate level of MDM. Therefore, with two of the three elements meeting the moderate level of MDM and the patient being new to the practice, you can assign 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) to report the E/M visit.

Next, you’ll look to the following codes to report the CT scan of the chest:

• 71250 (Computed tomography, thorax, diagnostic; without contrast material)
• 71260 (… with contrast material(s))
• 71270 (… without contrast material, followed by contrast material(s) and further sections)

Your code selection depends on whether the provider used contrast in the imaging exam. According to CPT^® guidelines, you may only report a “with contrast” code when the physician administered contrast material intravascularly (into the vein), intra-articularly (into the joint space), or intrathecally (into the spinal canal) — oral and rectal contrast administration does not count toward a “with contrast” imaging study.

Finally, you’ll open the ICD-10-CM code book to assign a code for the idiopathic pulmonary fibrosis diagnosis. In the Alphabetic Index, search for Fibrosis > pulmonary > idiopathic. Turn to the Tabular List to verify J84.112 (Idiopathic pulmonary fibrosis) as the correct code for the diagnosis.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC