Case
-T6-2B RADIOLOGY REPORT, CHEST
LOCATION: Inpatient, Hospital
PATIENT: Dennis Deitz
ATTENDING PHYSICIAN: David Barton, MD
RADIOLOGIST: Morton Monson, MD
CHEST, SINGLE VIEW, FINDINGS: This examination is compared to a previous examination dated September of this year. This examination is over-penetrated. There is evidence of prior CABG (coronary artery bypass graft). The heart size is mildly enlarged but unchanged when compared with the previous examination. The pulmonary vascular markings appear within normal limits. There is abnormal focal pulmonary density present within the left lung base. Previously, there was some opacity in this area; however, it has increased since the previous examination. This density may be related to atelectasis or infiltrate. This will require correlation with the patient's signs and symptoms.
IMPRESSION:.
1. Cardiomegaly without evidence for congestive failure.
2. Prior CABG.
3. Abnormal focal density (calcification) is present within the left lung base, which may be related to atelectasis or infiltrate.
T6-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 71010-26 (X-Ray, Chest)
ICD-10-CM DX: I51.7 (Hypertrophy, cardiac), Z95.1 (Status [post], aortocoronary bypass), J98.4 (Calcification, lung)
Explanation: The chest x-ray is stated to have been a single view. The -26 modifier is appended when reporting the professional service. The diagnoses are taken from the Impression section of the report. The postprocedural status of this patient prior to coronary artery bypass graft can impact the treatment and was mentioned by the radiologist in his report. Knowing when to code or not to code status post (S/P) conditions can be difficult for the new coder. Additional credit can be given for those who correctly identify this Z code.

Case -T6-2B RADIOLOGY REPORT, CHEST