Clinical history: Shortness of breath - crackles and change in sound in base of lungs.
Study performed: Chest X-ray, PA and lateral.
Impression: Poor inspiratory effort which accentuates the basilar lung markings and cardiac silhouette, partially limiting evaluation. Small vertically oriented linear infiltrate subsegmental atelectasis is noted in the L retrocardiac region adjacent to the diaphragm. There is minimal hazy increased density and decreased definition in the L costophrenic angle suggesting pleural effusion. Segmental atelectasis and some pleural effusion.
Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

71046 is the correct CPT code for a chest X-ray with two views, which matches the description of the study performed (PA and lateral views). J90 and J98.11 are the correct ICD-10-CM codes for pleural effusion and segmental atelectasis, respectively, which are the findings noted in the impression.

Clinical History: Shortness of Breath - Crackles and Change in Sound