ED Coding and Reimbursement Alert

Question: The provider performed an ED evaluation and management (E/M) service for a patient who was suffering from back pain. The E/M featured a detailed history, a detailed examination, and moderate-complexity medical decision making (MDM). The provider also performed a magnetic resonance imaging (MRI) with contrast materials to pinpoint the problem. Final diagnosis was “discitis multi regions.” How should I report this encounter? Do I need to report the back pain and the discitis?

Wisconsin Subscriber

Answer: You do not have to report the back pain, since the provider reached a diagnosis by the end of the encounter. So, you’ll append M46.49 (Discitis, unspecified, multiple sites in spine) to the E/M and MRI codes.

As for the codes, report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity…) for the ED E/M. The MRI, however, is where things get murky.

Why? Your description doesn’t indicate where in the spine the provider focused the MRI. Also, you must find out how the provider used contrast material during the MRI. Did they use contrast material only at the start of the MRI, or did they use contrast material only during further MRI sequences?

Do this: Go back and check the notes; or, if it’s possible, ask the provider:

• Where in the spine they performed the MRI, and
• how they used the contrast material during the MRI.

Then choose one of the following MRI codes:

• 72142 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s))
• 72147 (… thoracic; with contrast material(s))
• 72149 (… lumbar; with contrast material(s))
• 72156 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical)
• 72157 (… thoracic)
• 72158 (… lumbar).