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Find out if 72149 covers the S1 region.

Lower back pain can be, well, a pain to diagnose, treat, and code. Finding the correct code to match which area of the spine the provider imaged or remembering that spondylosis with stenosis requires more than one ICD-10-CM code can be enough to confuse even the most seasoned coder.

Look at this radiology report to see if you can correctly code the case study.

Read Through the Radiology Report to Find the Information You Need

Clinical History: A 75-year-old female patient with a history of osteoporosis, coronary artery disease (CAD), and spinal compression (20 years ago) presents with severe lower back pain. The patient doesn鈥檛 remember suffering any trauma but claims to have experienced lower back pain for the past four months.

Technique: Computed tomography (CT) scan with contrast injection of the lumbar spine; magnetic resonance imaging (MRI) of lumbar spine and S1 with contrast injection.

Impression:

1. MRI results show disc bulging and facet arthropathy resulting in severe canal stenosis at L3-4, moderate to severe stenosis at L4-5, and severe canal stenosis at L5-S1.
2. CT results show moderate to severe canal stenosis and left neural foramen stenosis at L2-3.
3. There is degenerative disc disease at L5-S1 and to a lesser extent L1-2 through L3-4.

Diagnosis: Lumbosacral spondylosis with stenosis, degenerative disc disease with disc herniation in the lumbosacral region.

After examining the radiologist鈥檚 report, your next step will be to determine which CPT^庐 and diagnosis codes to use for your report.

Disclaimer: To conserve space, we removed the findings section of the report. In this scenario, presume the findings didn鈥檛 provide any additional information you鈥檇 need to complete your report. In a real-world coding scenario, you鈥檇 want to double-check the information in the findings against the impression to ensure there aren鈥檛 any discrepancies or contradictions between the sections.

Pay Attention to Contrast to Find the Correct CPT^庐 Code

The technique section of the radiology report indicates the provider obtained CT and MRI images of the patient鈥檚 spine. You鈥檒l notice the radiologist performed the CT and MRI with contrast. Providers use contrast media to better visualize the body鈥檚 structures. However, not all contrast is the same in the eyes of payers or CPT^庐. 鈥淩emember, to bill for a study 鈥榳ith contrast,鈥� intravascular, intrathecal, or intra-articular contrast must be administered. Oral or rectal contrast alone doesn鈥檛 qualify,鈥� says Kristen Taylor, CPC, CHC, CHIAP, associate partner, Pinnacle Enterprise Risk Consulting Services.

Using the Spine section of the CPT^庐 code set Index, you鈥檒l find CT Scans and follow Spine > Lumbar to locate the code range. Knowing the radiologist performed the CT scan with contrast, when you turn to the Radiology section of the CPT^庐 code set, you鈥檒l find 72132 (Computed tomography, lumbar spine; with contrast material) that applies to the CT scan of the patient鈥檚 lumbar spine.

After verifying the CT scan code, you鈥檒l turn to the MRI procedure code. In this case, the radiologist captured MRI imaging with contrast.

When you look to the Magnetic Resonance Imaging area under the Spine section of the CPT^庐 code set Index, you鈥檒l follow Spine > Lumbar to arrive at the code choices. Since the radiologist captured images of the patient鈥檚 lumbar spine and S1, you鈥檒l assign 72149 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)) to report the MRI of the lumbar spine.

Will you need another MRI code to cover the S1 area? 鈥淚f an MRI of the sacrum was performed, code 72196 (Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)) is the appropriate code to report with contrast,鈥�,鈥� says Chelsea Kemp, RHIT, CCS, COC, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC-Approved Instructor, outpatient coding educator/auditor, Yale New Haven Health, New Haven, Connecticut. Even though the descriptor for 72196 lists the pelvis, a code representing an MRI of the pelvis is 鈥渢he appropriate code to report for an MRI of the sacrum鈥�contingent upon the use of contrast material,鈥� according to the June 2006 issue of CPT^庐 Assistant.

Look to Lumbosacral to Select Dx Codes

The report listed the diagnoses as spondylosis with stenosis and degenerative disc disease with disc herniation. For these diagnoses, you鈥檒l need multiple ICD-10-CM codes. One key piece of information from the radiology report is the term 鈥渓umbosacral鈥� when referring to the region where the conditions are occurring.

Starting with the spondylosis with stenosis, you鈥檒l need two separate codes. 鈥淭here is not a combination code for these two conditions,鈥� Taylor says. Look in the ICD-10-CM Alphabetic Index for Spondylosis > without myelopathy or radiculopathy > lumbosacral region, where you鈥檒l find M47.817 (Spondylosis without myelopathy or radiculopathy, lumbosacral region).

Next, you鈥檒l look for Stenosis, stenotic (cicatricial) (see also Stricture) in the Alphabetic Index. Following the indentations to spinal > lumbosacral, you鈥檒l find M48.07 (Spinal stenosis, lumbosacral region).

For the degenerative disc disease with disc herniation in the lumbosacral region, you鈥檒l refer to the M51.- (Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders) category. When you look up Degeneration, degenerative in the Alphabetic Index and follow the indentations to intervertebral disc > lumbosacral region, you鈥檒l find M51.37 (Other intervertebral disc degeneration, lumbosacral region).

Lastly, for the patient鈥檚 herniated disc diagnosis, you鈥檒l need to remember that disc displacement is another term for a herniated disc. If you follow Displacement, displaced > intervertebral disc > lumbosacral region, you鈥檒l find M51.27 (Other intervertebral disc displacement, lumbosacral region).

Coding reminder: After locating a code in the ICD-10-CM Alphabetic Index, remember to verify it in the tabular list. You鈥檒l often find additional instructions, coding notes, and ICD-10-CM guideline references in the tabular list that help you produce a foolproof claim.

Wrap Up the Report

How did you do? To recap this radiology report breakdown, you鈥檒l assign 72132, 72149, and 72196 to report the CT scan and MRI scans, respectively. For the diagnoses, you鈥檒l need four separate ICD-10-CM codes in your claim to ensure proper reimbursement 鈥� M47.817, M48.07, M51.37, and M51.27.