Radiology Coding Alert

See how all the 'suggested' diagnoses affect your ICD-9 options.

To help keep your coding in tip-top shape, read through the real-life report excerpt below, and then explore the "why" behind the codes you should and shouldn't choose.

Knock Out This Knee Scenario

Findings

Medial compartment: The medial meniscus is intact. The medial collateral ligament is unremarkable. Articular cartilage at the medial tibiofemoral compartment is preserved. There is mild insertional semimembranosus tendinosis, and some edema is noted tracking along the deep aspects of the gracilis and semitendinosus tendons. A trace amount of edema at the medial gastrocnemius origin suggests strain.

Lateral compartment: The lateral meniscus demonstrates extension of the cleft between the meniscofemoral ligament of Wrisberg and the posterior horn. The vertical cleft extends almost all the way to the posterior aspect of the mid body and suggests a "Wrisberg rip" posterior meniscal tear. There is mild edema noted superficial to the posterior horn along the posterior capsule. Within the posterior aspect of the lateral tibial plateau, there is a focal region of subchondral marrow edema extending over a medial to lateral dimension of 9 mm and an anterior to posterior dimension of 12 mm. The edema extends roughly 12 mm deep to the articular surface. This finding suggests a focal subchondral impaction of the posterolateral tibial plateau. At the lateral margin of this site of edema, there is suggestion of very subtle articular offset, on the order of 1 mm. No corresponding edema at the lateral femoral condylar sulcus is present to suggest a pivot-shift contusion pattern. The fibular collateral ligament, conjoined tendon, and popliteus tendon are all intact. There is edema deep to the iliotibial band suggesting mild iliotibial band syndrome.

Impression:

1. Focal subchondral impaction injury at the posterior lateral tibial plateau as described above with approximately 1 mm of offset at the articular surface.

2. No corresponding marrow edema in the lateral femoral condylar sulcus to suggest pivot-shift offset contusion pattern.

3. Intact cruciate ligaments.

4. Insertional semimembranosus tendinosis and mild edema surrounding the gracilis and semitendinosus tendons.

5. Mild iliotibial band syndrome with edema deep to the IT band.

6. Suggestion of nondisplaced vertical longitudinal tear of the posterior horn lateral meniscus as an extension of the cleft between the ligament of Wrisberg and the posterior horn, compatible with the so-called "Wrisberg rip" tear.

7. Posterior capsular sprain.

Narrow Your Choice to Single Procedure Code

To choose the appropriate procedure code for this case, take note of both the Examination and Technique sections:

• Examination: MRI Left Knee. No contrast.
• Technique: Standard, unenhanced imaging of the left knee.

Documentation of a knee MRI without use of contrast (confirmed by the term "unenhanced imaging") points you to a single code. The appropriate code for an MRI of the left knee with no contrast is 73721 (Magnetic resonance [e.g., proton] imaging, any joint of lower extremity; without contrast material), says Rita Huelar, CPC, who performs coding for Nemours Health System.

Remember to append modifier 26 (Professional component) if you're reporting only the physician's services (and not the technical component).

Tip: The American College of Radiology (ACR) offers knee MRI guidelines at www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/musc/mri_knee.aspx. For documentation, the guidelines recommend: "The report should address the condition of the menisci, major ligaments, articular cartilage, bone marrow, and extensor mechanism. In selected cases, a description of findings in the neurovascular structures, muscles and tendons, synovium, and cortical bone would be appropriate." (Keep in mind the ACR's note that the guidelines are a basic tool, meant to allow the physician flexibility to fit the individual patient's case.)

Limit ICD-9 Options to Confirmed Diagnoses

When you select your ICD-9 codes for the sample report, remember that you should not report a code for a diagnosis that the provider documents as suspected.

Rule: ICD-9 official guidelines for outpatient services state: "Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit," says Lori Hendrix, CPC, CPC-I, CPC-H, CIRCC, PCS, FCS, senior project coordinator, compliance department, for Wellstar in Georgia. (Guidelines are available for download from www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm.)

In 2005, Coding Clinic for ICD-9-CM (vol. 22, no. 3) stated that "consistent with," "compatible with," "indicative of," "suggestive of," and "comparable with" all indicate probable or suspected conditions (which you should not code as confirmed).

Apply the rule: In the sample case, the radiologist often uses variations of the word "suggest" in the Impression section. For example, Impression number 6 states, "Suggestion of nondisplaced vertical longitudinal tear of the posterior horn lateral meniscus as an extension of the cleft between the ligament of Wrisberg and the posterior horn, compatible with the so-called 'Wrisberg rip' tear." Because the radiologist uses the terms "suggestion of" and "compatible with," you should not report ICD-9 codes for a meniscal tear (836.1, Tear of lateral cartilage or meniscus of knee current).

You should instead report confirmed diagnoses related to the reason for the encounter, such as "Posterior capsular sprain" (Impression number 7). Look to 844.8 (Sprain of other specified sites of knee and leg) for this diagnosis, Hendrix says.

Similarly, the "Focal subchondral impaction injury" is confirmed. Because the code describing it, 959.7 (Other and unspecified injury to knee leg ankle and foot), states "other and unspecified," consider reporting the more specific and equally compliant 844.8 as your first-listed code, Hendrix suggests.

Remember: When the physician does not confirm a diagnosis, you may report the sign or symptom that prompted the diagnostic exam. For instance, you could report 719.46 (Pain in joint involving lower leg) because the test was ordered due to the patient's knee pain.

You should not report a diagnosis code based on the instruction to "evaluate for ACL tear," however. The Impression states the cruciate ligaments (including the anterior or ACL) are intact. Therefore the ACL tear is not a confirmed diagnosis, and you should not report a code for it.