Pulmonology Coding Alert

Question: I’m new to coding and I’m having trouble understanding a phrase on a medical report. The provider wrote “expiration CXR with mild atelectasis lung bases,” and the latter information was also identified under the findings.

What does this mean and what codes should I assign?

Codify Subscriber

Answer: Atelectasis is a total or partial collapse of the lung or lobe in the lung. The condition occurs when the lung’s alveoli deflate or fill with alveolar fluid. Patients can develop the condition after undergoing surgery. In the situation you’ve presented, the patient developed atelectasis in their lung bases. When referred to anatomically, the lung bases are the lower concave lung surfaces that touch the hemidiaphragms. At the same time, several providers use lung bases as a general term that refers to the lower area of the lungs.

To diagnose the condition, a provider will take a chest X-ray (CXR) with inspiration and expiration views to examine the lungs, heart, and other structures when the patient is inhaling (inspiring) and exhaling (expiring). An expiration CXR is an X-ray of the patient’s chest while the patient is breathing out.

Depending on how many views the provider captured of the patient’s chest, you’ll assign one of the following CPT® codes:

• One view: 71045 (Radiologic examination, chest; single view)
• Two views: 71046 (… 2 views)
• Three views: 71047 (… 3 views)
• Four views: 71048 (… 4 or more views)

You’ll assign J98.11 (Atelectasis) to report the provider’s findings of mild atelectasis of the lung bases.