Revenue Cycle Insider

Question: A 75-year-old patient presented to the pulmonologist with a chronic cough and unexplained weight loss. The pulmonologist performed a physical examination and ordered a high-resolution CT scan with contrast of the patient’s chest. After reviewing the CT scan results, the physician diagnosed the patient with mediastinal emphysema.

What codes should I report?

Oklahoma Subscriber

Answer: You’ll assign J98.2 (Interstitial emphysema) to report the mediastinal emphysema diagnosis. This code features mediastinal emphysema as an alternative condition listed under the code. To locate the code, search for Emphysema > mediastinal in the ICD-10-CM Alphabetic Index. You’ll then turn to the Tabular List to verify J98.2 as the correct diagnosis code.

Next, you’ll open the CPT^® code book. Use 71260 (Computed tomography, thorax, diagnostic; with contrast material(s)) to report the CT of the chest with contrast material. Remember that you can only report a “with contrast” imaging code if the contrast material is administered intravascularly, intra-articularly, or intrathecally. Otherwise, you’ll assign a “without contrast” CT scan code.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC