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Chapter 2: Chest (71010-71555)
Chest imaging exams — X-rays in particular — are among the most common diagnostic tests ordered and performed.
This chapter offers information to be sure you catch hidden coding opportunities along with explaining proper
application of chest imaging codes.
Tip: For information on CTAs, see "Special Feature: Keep Sight of Anatomic Site to Select CTA Code" in Chapter 1.
Capture Multiple Chest Exams
Your radiologist may interpret multiple chest exams for the same patient on the same day. The following scenarios
offer lessons you can apply anytime you consider coding multiple medically necessary exams on a single claim.
Separate Encounter Offers Mod 59 Opportunity
Scenario: You have a report for a two-view and single-view chest X-ray performed on the same date of service. The
physician ordered the two-view first and then had to order the single-view after the patient pulled his chest tube out.
Should you code for both?
Solution: Report 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the two-view. Then report
71010 (Radiologic examination, chest; single view, frontal) and append modifier 59 (Distinct procedural service) to the
single-view code.
Why? Correct Coding Initiative (CCI) edits bundle 71010 into 71020, but the edit has a modifier indicator of "1." The
"1" indicator tells you that you may override the edit when appropriate, specifically when the second service is
performed at a separate encounter or at a separate anatomic site.
Because the single-view was clinically necessary (following the patient removing his chest tube) and a separate
encounter, you may override the edit. Append modifier 59 to the column 2 code, 71010.
Choose 76 for 2 Interpretations by 1 MD
Scenario: Your clinic radiologist interprets two single-view chest X-rays for the same patient on the same date of
service, but each X-ray was ordered by a separate physician. How should you report the radiologist's services?
Solution: You should report 71010 (Radiologic examination, chest; single view, frontal) and 71010-76 (Repeat
procedure or service by same physician or other qualified healthcare professional) for the radiologist's interpretation of
these two films.
Even though two different physicians ordered the X-ray, you are reporting the same procedure (chest X-ray
interpretation) repeated by the same radiologist on the same date of service.
Note: If a patient receives two chest X-rays and they are interpreted by different physicians in the same group, you
should report 71010, 71010-77 (Repeat procedure or service by another physician or other qualified healthcare
professional).
Enter 71035 for Expiration View
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Scenario: Which codes should you report for inspiration and expiration views?
Solution: You should report the inspiration view with 71010 (Radiologic examination, chest; single view, frontal). And
report the expiration view with 71035 (Radiologic examination, chest, special views [e.g., lateral decubitus, Bucky
studies]).
Report 2-View Chest and Rib X-Rays Separately
Trying to get certain chest and rib exams paid together can spell trouble.
Example: The radiologist performs a two-view chest (71020, Radiologic examination, chest, 2 views, frontal and
lateral) and unilateral ribs (71100, Radiologic examination, ribs, unilateral; 2 views) on the same date for the same
patient. Some coders report that insurance denies the rib X-ray, refusing to pay the two separately.
Reality: Codes 71020 and 71100 are the correct codes for this service and should be reported separately. The Correct
Coding Initiative (CCI) edits no longer bundles these codes, so you should not need a modifier to report the two
together.
Don't miss: If the provider instead performed a single-view (PA) chest and unilateral rib X-ray, you should look for the
single code that describes both services rather than reporting them separately, such as 71101 (Radiologic
examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views).
Payers should reimburse both 71020 and 71100 because they involve separate films taken to evaluate different
anatomic structures. Options: You can find out whether your payer will cover the exams if you append modifier 59
(Distinct procedural service) to the rib exam. If not, you'll have to decide whether you want to appeal. If so, be sure to
include the information that CCI deleted this edit.
Pre-Op Chest X-Ray? Watch Your ICD-9 Codes
According to the ICD-9 official guidelines, "For patients receiving preoperative evaluations only, sequence first a code
from category V72.8x (Other specified examinations), to describe the pre-op consultations. Assign a code for the
condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the preop evaluation."
For example: If your radiologist reads a pre-knee replacement two-view chest X-ray ordered for a patient with chronic
obstructive pulmonary disease (COPD), you should report 71020 (Radiologic examination, chest, 2 views, frontal and
lateral).
Link V72.82 (Pre-operative respiratory examination) to 71020 as the primary diagnosis.
Report the appropriate code showing medical necessity for the surgery, such as 715.96 (Osteoarthrosis, unspecified
whether generalized or localized, lower leg).
And code relevant findings, such as diagnosis code 492.8 (Other emphysema).
Good news: Medicare and other payers typically cover medically necessary preoperative chest X-rays.
Bonus tip: Other preoperative X-ray codes you may encounter include:
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V72.81— Pre-operative cardiovascular examination
V72.83 — Other specified pre-operative examination
V72.84 — Pre-operative examination, unspecified.
Special Feature:
Pick Proper Portable X-Ray Code
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If you are reporting X-rays taken using portable equipment and billing only the interpretation (professional component)
of the service, you should report the same service code from the 70010-79999 range you would report for nonportable services.
Example: The radiologist interprets a two-view chest X-ray taken at a physician office using a portable device. You
should report his service with 71020-26 (Radiologic examination, chest, 2 views, frontal and lateral; Professional
component). Coding is a little trickier if you're reporting portable X-ray transportation. To report the transportation, use
R0070 (Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or
location, one patient seen) when the personnel see one patient and R0075 (Transportation of portable X-ray
equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen) to
report imaging multiple patients at the same location.
If you report R0075, you also need to append a modifier to show how many patients the personnel saw:
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UN — Two patients served
UP — Three patients served
UQ — Four patients served
UR — Five patients served
US — Six or more patients served.
Key: Report R0070 and R0075 when you transport the equipment, not when the facility the personnel travel to stores
the equipment.
Example: You need to report portable X-ray transportation and a global two-view chest X-ray for one patient and a
complete ankle X-ray for a second patient at a skilled nursing facility (SNF).
You should report 71020 and R0075-UN for patient one and 73610 (Radiologic examination, ankle; complete, minimum
of 3 views) and R0075-UN for patient two. Medicare will prorate R0075 payment between the two patients. For the
services provided at the SNF, you should report POS 31 (Skilled nursing facility).
Coverage: CMS indicates the following items as eligible for portable X-ray coverage:
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Skeletal films involving the extremities, pelvis, vertebral column, or skull
Chest films which do not involve the use of contrast media (except routine screening procedures and tests in
connection with routine physical examinations)
Abdominal films which do not involve the use of contrast media
Diagnostic mammograms if the approved portable X-ray supplier, as defined in 42 CFR part 486, subpart C, meets
the certification requirements of section 354 of the Public Health Services Act, as implemented by 21 CFR part 900,
subpart B.
Don't Forget Cat. III Chest X-Ray CAD Codes
Back on Jan. 1, 2007, two new Category III codes took effect for chest X-ray CAD, in response to provider requests:
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+0174T — Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection)
with further physician review for interpretation and report, with or without digitization of film radiographic images,
chest radiograph(s), performed concurrent with primary interpretation (list separately in addition to code for primary
procedure) (use 0174T in conjunction with 71010, 71020, 71021, 71022, 71030)
0175T — Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection)
with further physician review for interpretation and report, with or without digitization of film radiographic images,
chest radiograph(s), performed remote from primary interpretation (do not report 0175T in conjunction with 71010,
71020, 71021, 71022, 71030).
You should use +0174T with the originating chest X-ray CPT® code (note the codes listed in the descriptor). But 0175T
is a stand-alone code that is not inclusive of the chest X- ray. So when that chest X-ray CAD is performed at a different
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time, location, or by another physician than the original chest X-ray, use 0175T.
Special Feature:
Keep Plane and View Definitions Clear
The different planes for radiological services include:
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Coronal (frontal): This is the vertical plane dividing the body into front and back sections
Sagittal: This vertical plane divides the body into equal left and right sections
Transverse: This horizontal plane divides the body into top and bottom sections.
Views you'll see radiologists document include the following:
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Anteroposterior (AP): front to back
Apical: chest including lung apex to minimize the rib image overlapping a lung lesion
Bucky: film placed in a device that eliminates secondary radiation
Decubitus (DEC): lying on side
LAO (left anterior oblique): left front
LPO (left posterior oblique): left rear
Oblique: angled view
Odontoid: open-mouth cervical spine view to identify joint space C1
Posteroanterior (PA): back to front
RAO (right anterior oblique): right front
RPO (right posterior oblique): right rear
Stereo: two views of a structure, one at 90 degrees to the film and second with tube angled 12 degrees to 15 degrees
toward the head
Swimmers: thoracic X-ray with one or both arms over head.
You may also see directions and positions such as the following:
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Anterior (ventral): front
Distal: farthest away from center
Inferior: below
Lateral: side
Medial: middle
Posterior (dorsal): back
Prone: face down or palm down
Proximal: nearest to the center
Superior: above
Supine: face up or palm up.
Example: When you report 71020 (Radiologic examination, chest, two views, frontal and lateral), you're reporting
chest views taken from the front and the side. If the radiologist adds oblique (angled view) projections, you should
report 71022 (... with oblique projections) instead.
Set Yourself Up for 'Sniff' Test Success
For a fluoroscopic "sniff' test to evaluate diaphragmatic motion, take note of whether the study produces films.
Report 76000 (Fluoroscopy [separate procedure], up to 1 hour physician or other qualified professional time, other
than 71023 or 71034 [e.g., cardiac fluoroscopy]) if the radiologist produces no films.
Watch out: Your payer may not cover a sniff test with no films, but you must code the procedure as performed.
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If the procedure produces a two-view chest X-ray with the fluoroscopic test, report 71023 (Radiologic examination,
chest, 2 views, frontal and lateral; with fluoroscopy).
For four or more views, report 71034 (Radiologic examination, chest, complete, minimum of 4 views; with fluoroscopy).
Your most likely ICD-9 option is 519.4 (Disorders of diaphragm), but you should report only the diagnosis documented
by the physician.
Note: The name "sniff" test stems from the physician using fluoroscopy while the patient sniffs to allow the physician
to test for diaphragm paralysis.
71035 OK for More than Bucky
CPT® lists a couple of the views that qualify as "special" in the descriptor for 71035 (Radiologic examination, chest,
special views [e.g., lateral decubitus, Bucky studies]).
In addition to lateral decubitus and Bucky studies, other views experts suggest as 71035-appropriate to include the
following:
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The apical lordotic view, which has the central ray angled up toward the patient's head to allow visualization of the
uppermost parts of the lungs
The AP expiration view, which is just a single-view chest taken with the patient in full exhalation instead of full
inhalation.
Special Feature:
Dig Into Diagnostic Indicator Meaning
You can find diagnostic imaging family indicators in the Medicare Physician Fee Schedule (MPFS):
1.
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6.
7.
8.
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10.
11.
= Family 1 Ultrasound (chest/abdomen/pelvis — non obstetrical)
= Family 2 CT and CTA (chest/thorax/abdomen/pelvis)
= Family 3 CT and CTA (head/brain/orbit/maxillofacial/neck)
= Family 4 MRI and MRA (chest/abdomen/pelvis)
= Family 5 MRI and MRA (head/brain/neck)
= Family 6 MRI and MRA (spine)
= Family 7 CT (spine)
= Family 8 MRI and MRA (lower extremities)
= Family 9 CT and CTA (lower extremities)
= Family 10 MR and MRI (upper extremities and joints)
= Family 11 CT and CTA (upper extremities).
Resource: CMS lists these indicators in the Medicare Claims Processing Manual, Chapter 23, "Fee Schedule
Administration and Coding Requirements" (http://www.cms.gov/manuals/downloads/clm104c23.pdf).
Number of Views Can Change Rib Coding
Your rib coding options include the following:
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71100 — Radiologic examination, ribs, unilateral; 2 views
71101 — ... including posteroanterior chest, minimum of 3 views
71110 — Radiologic examination, ribs, bilateral; 3 views
71111 — ... including posteroanterior chest, minimum of 4 views
Note that to code three views of the ribs (unilateral) with no chest involved, you should report 71100.
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Why: If your documentation shows no films of the patient's chest, you can't report three-view code 71101, which
specifically includes "posteroanterior chest" in its descriptor.
Watch for: Check the documentation to confirm the exact description of the three views that the radiology
technologist performed. The radiologist or technologist may document that the third rib view was indeed a single-view
chest, although with different exposure factors than a practitioner might use to detect primary pulmonary pathology.
Because 71101's descriptor doesn't specify radiographic technique, if your technologist performed a chest view along
with the rib views, you should report 71101.
Case Study:
CT scan of the Chest, Abdomen, and Pelvis with Contrast
Analyze the documentation below, and see if you can spot the proper codes.
Clinical History: Follow-up sigmoid colon cancer with pulmonary metastasis.
CT Scan of the Chest, Abdomen, and Pelvis With Contrast
Technique: 5-mm sections through the chest, abdomen, and pelvis were obtained with 100 cc of Isovue 300 (nonionic) contrast agent intravenously without incident, and oral contrast and images viewed in soft tissue, lung, and liver
windows. Comparison is made with a previous examination performed on [date deleted].
Indication for the use of non-ionic contrast: No specific indication given.
Findings: Again, there are several pulmonary nodules bilaterally, consistent with metastases. The majority of the
previously seen nodules have either decreased in size or resolved. There are new pulmonary nodules. The previously
seen scattered ground glass opacities, most prominent at the left lung base, have resolved. The previously seen
prominent subcarinal and left hilar lymph nodes have decreased in size as well. Subcarinal lymph node measures 7
mm x 19 mm on image #28. Previously, it measured 11 mm x 26 mm.
There is no bulky axillary, mediastinal, or hilar lymphadenopathy. The heart is stable. Left subclavian Infuse-A-Port
catheter has been placed in the interim.
Previously noted hypodensity within the dome of the liver is less conspicuous and actually appears to be volume
averaging within the perihepatic fat. The hypodensity within the medial aspect of the left hepatic lobe is adjacent to
the falciform ligament in a good place for fatty infiltration. Otherwise, the liver is normal. Gallbladder, spleen, pancreas,
adrenal glands, and kidneys are stable. A simple cyst is seen within the parapelvic region of the right kidney.
There is moderate symmetric concentric thickening involving the distal sigmoid colon which is less nodular when
compared to previous examination. Again, there is mild increased attenuation of the perisigmoid and rectal fat, which
may be related to radiation therapy changes. There is mild sigmoid and descending colon diverticulosis. Otherwise, the
bowel is unremarkable. No bulky lymphadenopathy or ascites. Mildly prominent celiac axis lymph node is unchanged.
Best seen on image #86, just posteromedial to the spleen, there is a 6- x 15-mm soft tissue density nodule along the
posterior peritoneal surface that is nonspecific but unchanged from prior examination.
Impression:
1. Persistent but improved bilateral pulmonary metastases.
2. Mildly prominent subcarinal and left hilar lymph nodes have decreased in size. Mildly prominent celiac axis lymph
node is stable.
3. Hepatic hypodensities likely represent a combination of volume averaging and focal fatty infiltration. There is no
new hepatic lesion to suggest metastasis.
4. Persistent left nodular sigmoid colon wall thickening. Adjacent mesenteric and induration may be related to
radiation therapy changes.
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5. Small nodule along the left posterior peritoneal surface is stable.
Codes Revealed
1. CT chest with IV contrast: 71260 (Computed tomography, thorax; with contrast material[s]) and 197.0 (Secondary
malignant neoplasm of lung)
2. CT abdomen and pelvis with IV contrast: 74177 (Computed tomography, abdomen and pelvis; with contrast
material[s]) and 153.3 (Malignant neoplasm of sigmoid colon)
3. 100 units of contrast: Q9967 (Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml).
Don't Overload Claim With Background Codes
Outpatient note: You don't need to include a code to indicate that the patient has been undergoing radiation
therapy. Unlike hospital medical records abstraction, with outpatient reimbursement coding, you must establish
medical necessity, and once that has been established, you aren't required to add additional diagnoses.
You also don't need to change your coding just because this is a follow-up exam. The findings confirm the reason for
these studies.
Room for Improvement
One problem with the documentation is the fact that there are multiple studies documented as one continuous report.
If you report all studies, an insurance auditor who reviews the report during a post-payment audit may say that you
need "separate and distinct" documentation for each CPT® code. The auditor might approve payment for only the
code with the lowest relative value units (RVUs) of the three exams.
Special Feature:
Capture Pay for Chest CT Reformatted Into Spine Exam
Many facilities perform a chest CT scan (71260) on a trauma patient and reformat the data into a spine exam (72129
or 72132). Therefore, you have a report for the CT chest and a separate report for the CT spine.
For the physician's professional service, you may code both. The Spring 2006 issue of the AMA's Clinical Examples in
Radiology indicates that you can report the spine CT code legitimately when the radiologist does a full and complete
spine interpretation.
The article notes, "If a full and complete spine interpretation is requested subsequently from reconstructed data (e.g.,
from the trauma series performed for abdomen evaluation), it is appropriate to code for the additional professional
services by reporting the appropriate 70000 series CT CPT® code(s) appended by modifier 26."
Although this Survival Guide is aimed at physician coding, you might be interested in knowing that the facility charge
is more problematic. You'll find general agreement that it is not appropriate for the facility to receive full payment for
two CT scans when there was only one image acquisition. However, that's about as far as the agreement goes.
The American Hospital Association's Third Quarter 2006 Coding Clinic for HCPCS states, "Although the images were
reconstructed to show images of the lumbar spine, an additional code for the reconstructed image of the lumbar spine
is not required since this did not require a rescanning of the patient."
Therefore, some payers may follow that advice and not reimburse the facility for the spine exam, while others might
be more flexible.
Clinical Examples in Radiology recommends the use of modifier 52 (Reduced services) on the technical component
charge, which is an option if the payer is willing to offer reduced reimbursement.
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As always, check your payers' policies for reporting preferences.
Put CTA Postprocessing Question to Rest
3-D rendering dictation qualifies as "image postprocessing" for computed tomographic angiography (CTA).
Imaging postprocessing refers to CT dataset 2-D and 3-D reconstructions.
The provider creates the 2-D reformatted images in multiple planes, and then can interpret, annotate, and archive
them as hard copy, electronic files, or both. The provider typically evaluates 3-D or volume-rendered reconstructions in
multiple projections. The work of 3-D reformatting is quite extensive, usually performed on a separate workstation.
One of the main differences between CT and a typical CTA is that CTA includes angiographic image reconstruction
postprocessing and interpretation.
Example: A physician orders a CTA for a patient with a suspected pulmonary embolism using a multidetector-row CTA
to visualize the vessels. The radiologist documents 3-D rendering.
You should use 71275 (Computed tomographic angiography, chest [noncoronary], with contrast material[s], including
noncontrast images, if performed, and image postprocessing) for reporting the rendered service.
- Published on 2015-01-01
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