Orthopedic Coding Alert

Question: A patient with degenerative disc disease reports to the orthopedist complaining of numbness in their spine and muscle weakness. The orthopedist asks the patient about the location, duration, and severity of the pain; they also review the patient’s medical history and recent activities to see if anything might have triggered the symptoms. Then the orthopedist performs an examination primarily concerned with the patient’s spine, legs, and neurological function. They also perform several tests to check for muscle weakness, sensory loss, or reflex changes. The surgeon then orders a lumbar magnetic resonance imaging (MRI) with contrast materials at our facility, which confirms the presence of left-sided sciatica with lumbago. How should I report this encounter?

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Answer: For this claim, you’ll report:

• 72149 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)) for the MRI
• The appropriate-level evaluation and management (E/M) code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) code set
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to the E/M code to show that the E/M and MRI were separate, significantly identifiable services
• M54.42 (Lumbago with sciatica, left side) appended to 72149 and the E/M code to represent the patient’s sciatica
• M51.36 (Other intervertebral disc degeneration, lumbar region) appended to 72149 and the E/M code to represent the patient’s disc degeneration

2 Dx codes: In addition to the sciatica, you should report the disc degeneration, as it is medically relevant. Often, patients that acquire sciatica suffer from another spinal issue, as this patient does.