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Question: I have a radiology report where the radiologist performed a CT scan of the patient鈥檚 left foot and ankle to evaluate the body structures for the potential of gout. The findings are idiopathic chronic gout of the left ankle.

What codes will I assign for the encounter?

Wyoming Subscriber

Answer: You鈥檒l assign 73700 (Computed tomography, lower extremity; without contrast material) to report the CT scan of the foot and ankle. The CPT^庐 coding guidelines indicate that 鈥渨ith contrast鈥� codes only apply to intravenous (IV), intraarticular, and intrathecal contrast administration. Since you didn鈥檛 indicate if contrast was administered using the aforementioned methods, or administered at all, you can report as an imaging examination without contrast.

Next, you鈥檒l use the ICD-10-CM code book to assign a code for the idiopathic chronic gout of the left ankle. Assign M1A.072- (Idiopathic chronic gout, left ankle and foot) with an applicable 7^th character to report the diagnosis. According to the parent code, the 7^th character options for the category are as follows:

• 0 = without tophus (tophi)
• 1 = with tophus (tophi)

A tophus is a painful lump that develops in the soft tissue over a gout-affected joint. If the documentation indicates the patient had a tophus or multiple tophi, you鈥檒l assign M1A.0721 (Idiopathic chronic gout, left ankle and foot, with tophus (tophi)). However, if the physician did not indicate a growth or noted there wasn鈥檛 a tophus present, you鈥檒l report M1A.0720 (Idiopathic chronic gout, left ankle and foot, without tophus (tophi)).

Mike Shaughnessy, BA, CPC, Development Editor, AAPC