A patient had symptoms of cough and wheezing an xray was preformed the x ray showed a collapsed lung. A few days later a follow up x ray was performed and the findings were normal. What diagnosis codes should we use to bill the follow up x ray?
If this is an outpatient or provider-based office: If the collapsed lung was the reason for the follow up x-ray you can report the collapsed lung diagnosis code.
Per the 2021 ICD-10-CM Official Coding Guidelines:
K. Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.