ICD 10 Coding Alert

Question: A referring doctor sends a patient to us for a magnetic resonance imaging (MRI) scan of the spine due to lumbar radiculopathy. Our radiologist documents a diagnosis of lumbar spondylosis in the impression. Would you code this as lumbar spondylosis with radiculopathy?

Oregon Subscriber

Answer: The answer depends on what’s documented in the indication of the dictation report. Just because the doctor ordered imaging with a particular diagnosis doesn’t always mean that the same diagnosis makes its way into the indication. Assuming that the indication makes a reference to lumbar radiculopathy, then you may report code M47.26 (Other spondylosis with radiculopathy, lumbar region).

Beginning radiology coders sometimes presume that you may either code from the indication or impression, but not both. In reality, there exist many instances in which will have to combine the information included in the indication with what’s documented in the impression. The same concept applies to the findings, in applicable instances.