CT Scan of the Chest and Adrenals
History: Left pulmonary nodule on chest x-ray
Technique: Helical transaxial images, 7 mm, of the chest were obtained after the administration of oral and intravenous contrast.
Findings: The patient's chest x-rays from February 24 and 25 were reviewed. There is an ill-defined opacity suggested in the left midlung zones on those studies, including oblique views.
Within the left lower lobe laterally, there is an approximately 2-cm area of parenchymal density that has the appearance of interstitial changes without findings of a significant nodule or mass. This finding can relate to scarring. There is no other nodule, mass, or effusion. Within the mediastinum, there is no evidence of adenopathy seen. The heart and great vessels are normal in appearance. There is a suggestion of minimal pericardial thickening anteriorly that is not specific. Osseous structures show degenerative changes with osteophyte formation at multiple levels in the thoracic spine.
Visualized upper abdominal structures, including liver, spleen, kidneys, pancreas, aorta, and para-aortic retroperitoneum, show no specific finding. The adrenal glands are not enlarged.
Impression: There is a small focal area of increased parenchymal density that has an interstitial pattern. There is no significant nodule or mass. This is suggestive of scarring. There is no nodule, mass, effusion, or adenopathy seen. Consider chest x-ray follow-up of this lesion to assess stability.
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct ICD-10-CM code for the findings described is J98.4, which refers to other disorders of lung, including lung scarring, which matches the impression of a small focal area of increased parenchymal density suggestive of scarring. The correct CPT code for the procedure is 71270, which is for a CT scan of the chest with contrast, as the technique mentions the administration of oral and intravenous contrast.