Radiology Coding Alert

Put your coding skills to the test with this scenario.

Radiology coders need to sift through a wide variety of reports to ensure an accurate claim. Look at the report below, and see if you can determine the correct codes to deliver a bulletproof report.

Disclaimer: To conserve space, we removed the findings section of the report. In this scenario, presume the findings didn’t provide any additional information you’d need to complete your report. In a real-world coding scenario, you’d want to double-check the information in the findings against the impression to ensure there aren’t any discrepancies or contradictions between the sections.

Radiology Report

Exam: MRI Left Forefoot

Indication: Pressure ulcer of other site, stage 4 (CMS/HCC) (HCC)

Technique: Multiplanar, multisequence noncontrast MR imaging was obtained of the left forefoot.

Impression:

1. Ulcer plantar to the 2nd metatarsal head. Mild bone marrow edema in the 2nd metatarsal head may be due to early osteomyelitis. There is no cortical destruction.
2. Degenerative changes of the MTP and TMT joints. The 2nd toe is dorsally dislocated at the 2nd MTP joint.
3. Diffuse soft tissue edema throughout the forefoot. No abscess.

After examining the radiologist’s report, your next step will be to determine which CPT^® and diagnosis codes to use.

Pick Out the Correct Procedure Code

The technique indicates the radiologist obtained magnetic resonance imaging (MRI) of the left forefoot, otherwise known as “lower extremity other than joint” per CPT^®. Additionally, the modality in the technique includes the phrase “noncontrast,” which tells you the radiologist performed an MRI without contrast. When you turn to the Radiology section of the CPT^® code set, you’ll want to focus on the section titled, “Lower Extremities.” This is where you’ll find CPT^® code 73718 (Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)) to document the procedure. If you had a similar procedure that included contrast media, then you’d assign 73719 (…; with contrast material(s)).

Dive Into the Diagnoses Codes

After you’ve correctly identified the procedure code for the report, you’ll move on to determining the correct diagnosis codes for the radiologist’s conclusions. By examining the impression and findings, you’ll have a good understanding of what took place during the exam. The impression is “where the radiologist is providing that final conclusion, the final diagnoses, and their true, expert opinion,” says Jennifer Bash, RHIA, CIRCC, RCCIR, CPC, RCC, Director of Coding Education for Advocate Radiology Billing Specialists. Bash continues, “Without an impression, [the radiologist is] really leaving what was important on that report up to the coder.”

As you can see in the indication, you’re dealing with a patient who is experiencing a pressure ulcer, and when you examine the impressions, the physician located the ulcer plantar at the 2nd metatarsal head. When you follow the ICD-10-CM Alphabetic Index, you’ll notice there isn’t a code for foot under ulcer > pressure > stage 4 (healing) (necrosis of soft tissues through to underlying muscle, tendon, or bone). Instead, you’ll follow the code for specified site NEC, which in this case is L89.89 (Pressure ulcer of other site).

Parent code L89.89 carries a 6th character indicator, so you need to find a more appropriate code to meet the requirements. For this case, L89.894 (Pressure ulcer of other site, stage 4) is listed and matches what the radiologist supplied in the indication.

If we remain in the 1st impression in the radiology report, you’ll see the wording, “Mild bone marrow edema in the 2nd metatarsal head.” The ICD-10-CM code set lists parent code R60.- (Edema, not elsewhere classified) with requiring a 4th character. The three edema code options include:

• R60.0 (Localized edema)
• R60.1 (Generalized edema)
• R60.9 (Edema, unspecified)

We can eliminate R60.9, as the report specifies the location of the edema. Generalized edema is a condition that affects the entire body, whereas localized edema is isolated to a specific body area — in this case, the 2nd metatarsal head. Additionally, you’ll use another R60.0 to code the diffuse soft tissue edema listed later in the impression.

Next, the impression lists “Degenerative change of the MTP/ TMT joints” in the report. However, when you search for “Degeneration, degenerative” in the Alphabetic Index, the term “joint disease” directs you to Osteoarthritis. Following Osteoarthritis to foot joint, you’ll discover M19.07 (Primary osteoarthritis ankle and foot). This parent code carries a 6th character required icon to specify laterality. ICD-10-CM code M19.072 (Primary osteoarthritis, left ankle and foot) meets the requirements for this condition.

Remember: When used in a code title, the word “and” should be read to mean either “and” or “or” according to section I.A.14 of the ICD-10-CM guidelines. Therefore M19.072 applies to the degenerative changes of the left foot joints, even though the radiologist didn’t examine the ankle.

The last diagnosis code for this report is the dislocation of the 2nd toe. If you follow Dislocation > foot or toe in the Alphabetic Index, you’re directed to Dislocation, toe. Under Dislocation > toe (s), you’ll find lesser S93.106, which leads you to metatarsophalangeal joint S93.12. This will be the best option since the impression states the dislocation happened at the 2nd MTP joint. Ultimately, the 6th character requirement of parent code S93.12 (Dislocation of metatarsophalangeal joint) will deliver you to S93.125 (Dislocation of metatarsophalangeal joint of left lesser toe(s)). However, S93.125 carries a 7th character required icon, meaning you’ll need to specify if this is an initial encounter, subsequent encounter, or sequela.

In summary, you’ll code this report with CPT^® code 73718 followed by ICD-10-CM codes L89.894, R60.0, M19.072, S93.125A, and R60.0.