Orthopedic Coding Alert

Question: Encounter notes indicate that the orthopedist performed a magnetic resonance imaging (MRI) on a patient’s right shoulder, confirming osteolysis. I am vaguely familiar with osteolysis and its treatment, but could you explain how to report this encounter?

Georgia Subscriber

Answer: First, we’ll run down your coding options, followed by a brief primer on the ins and outs of osteolysis.

CPT^® coding: You’ll choose one of the following codes for the MRI, depending on encounter specifics:

• 73218 (Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s))
• 73219 (… with contrast material(s))
• 73220 (… without contrast material(s), followed by contrast material(s) and further sequences)

Modifier: Be sure to append modifier RT (Right side) to the MRI code you choose to indicate laterality, if the payer requires it.

ICD-10 coding: Append M89.511 (Osteolysis, right shoulder) to the MRI code to represent the patient’s osteolysis.

Background: According to Codify, “osteolysis of an unspecified site refers to progressive destruction or degeneration of the bony tissue, which may occur due to disease, infection, or tumor, resulting in severe weakness of bone.”