Orthopedic Coding Alert

Question: How should I code "MRI of LS spine and sacrum and coccyx"? My radiology tech documented this procedure, but I can't find a code for it.

Indiana Subscriber

Answer: You should report a pelvis MRI code (72195-72197) when you examine the sacrum and sacroiliac joints with magnetic resonance imaging. One pelvis code  should cover both the sacrum and coccyx MRI.

You may report one of the following lumbosacral (LS) spine MRI codes separately as long as you have orders, medical necessity and documentation for both studies. The correct codes will depend on the documentation of contrast:

• 72148 " Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material
• 72149 "... with contrast material(s).

Example: Your chart shows that the physician performed all studies with contrast. You should report 72196 (Magnetic resonance [e.g., proton] imaging, pelvis; with contrast material[s]) and 72149.

-- Reader Questions and You Be the Coder were reviewed by Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC; and Bill  allon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.