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Exam Coding: CPT, ICD-10 and Matching the Order
CPT codes say what you did, ICD-10 codes say why. The reason must support the exam, and you bill only the views actually performed.
Two code sets
Two code sets travel with every exam. CPT (Current Procedural Terminology, from the American Medical Association) uses five-digit codes for the procedure performed. Many radiography codes are defined by body part and number of views: 73100 is a wrist, 2 views, and 73110 is a wrist, minimum of 3 views. A chest is 71045 for a single view and 71046 for 2 views. ICD-10-CM codes are alphanumeric, 3 to 7 characters, and describe the diagnosis or reason for the exam. M25.531 means pain in the right wrist, and external-cause codes add how it happened, such as a fall. In outpatient coding, a rule-out diagnosis is not coded as if confirmed; the symptom is coded instead. Radiographers rarely assign codes, but they verify that order, indication and exam match.