Radiology Coding Alert

Can you pinpoint the ideal imaging code?

Choosing the correct diagnostic imaging code to match the radiologist’s report is essential, as is selecting the correct ICD-10-CM code to match the diagnosis. Knowing how to interpret a diagnosis of myeloma without any mention of relapse or remission can be tricky even for experienced coders.

Read through this radiology report to see if you can choose the correct codes for this case study.

Review the Documentation to Find the Information You Need

Clinical History: A 70-year-old male patient presents to urgent care with complaints of lower back pain. The patient was seen by his primary care physician (PCP) two weeks ago for the same issue, and the patient was initially treated for a back strain with heat, nonsteroidal anti-inflammatory drugs (NSAIDs), and back exercises. The patient doesn’t have a history of cancer.

The patient states he’s experienced intermittent dull aching pain in his lower back for two to three months, plus radiating pain from his left buttock to the outer thigh and occasionally to the top of his foot. The patient denied any injuries, falls, trauma, or new physical activities, but stated the pain is affecting his daily activities and sleep at night.

The patient experiences minimal relief with 600 mg of ibuprofen three times a day.

Technique: A physical exam found spinous process tenderness of the L4 region and reduced strength of the left leg. I ordered magnetic resonance imaging (MRI) without contrast over computed tomography (CT) and X-rays due to the neurologic issues.

Findings: MRI of lumbar spine revealed widespread lytic lesions in the lumbar spine consistent with metastatic cancer or myeloma. Near complete replacement of L4 vertebrae from the tumor with invasion into the epidural space and impaction of nerve root. Laboratory testing confirms suspicions of myeloma.

Impression: Multiple myeloma of the lumbar spine.

The radiology report confirms the patient underwent an MRI of the lumbar spine without contrast. How would you code the MRI with interpretation of the results, and, based on the Findings, how would you code the diagnosis?

Master the Lumbar Spine MRI Codes

When you review the documentation, you’ll see the provider chose to perform MRI over CT scans and X-rays due to the patient’s radiating pain. Since the pain is originating in the lumbar spine, MRI is the preferred modality for evaluating the patient. MRI provides a clear view of the bones, muscles, nerves, discs, and other connective tissue of the patient’s spine. The technique also allows the provider to view the spinal cord and how the structures align. At the same time, the patient is complaining of pain radiating down his legs and sometimes to his foot. MRI can help evaluate the evidence of peripheral neurologic issues, as evaluated during the physical examination.

In the American Medical Association’s (AMA’s) CPT^® index, you’ll start by searching for “Magnetic Resonance Imaging.” Under that term, you’ll find “Diagnostic,” followed by “Spine,” and finally “Lumbar” to arrive at the code selections for a lumbar spine MRI. When you turn to the CPT^® code set’s Radiology chapter to verify the correct code, you’ll discover the difference between the three lumbar spine diagnostic MRI code choices relies on the provider’s use of contrast.

Lumbar spine diagnostic MRI code choices are as follows:

• 72148 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material)
• 72149 (… with contrast material(s))
• 72158 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar)

You’ll assign 72148 since the report states the provider performed an MRI without contrast. However, if the use of contrast isn’t mentioned in the report, then you should confirm with the provider. “When information is missing, coders are instructed to query the provider to obtain the additional information necessary to ensure the correct coding assignment. Coders should never assume, rather they should work closely with their provider(s) to ensure complete and accurate documentation, which in turn results in correct coding,” says Jennifer M. Connell, BA, CPPM, CPCO, CDEO, CPMA, CPB, CRC, COC, CPC, CPC-P, CPC-I, CCC, CCVTC, CEMC, CENTC, CFPC, CGIC, CGSC, CHONC, CUC, ROCC, CEMA, CMCS, CMRS, AAPC-Approved Instructor, revenue cycle director of Citizens Medical Professionals in Victoria, Texas.

What Is Myeloma?

Myeloma, or multiple myeloma, is a malignancy (cancer) of the body’s plasma cells. The plasma cells are white blood cells that produce the antibodies needed to fight infection. When the plasma cells become abnormal, produce abnormal paraprotein, and amass in the bone marrow, the plasma cells can interfere with normal blood cell production.

Patients may experience frequent infections, bone pain, pathological fractures, weakness, fatigue, neurologic dysfunction due to compressed nerves, and other symptoms if they’re suffering from multiple myeloma.

Remember to Select the Correct 5^th Character

In the Alphabetic Index, the diagnosis is listed as “Myeloma (multiple)” and features the code C90.0- (Multiple myeloma), which you’ll then verify in the tabular list. When you turn to Chapter 2: Neoplasms (C00-D49) in the ICD-10-CM code set tabular list, you’ll find that C90.0- requires a 5th character to complete the code. In this code subcategory, the 5th character specifies if the patient’s cancer is in remission, in relapse, or if the patient currently has the cancer.

The code options for multiple myeloma in the ICD-10-CM code set include:

• C90.00 (Multiple myeloma not having achieved remission)
• C90.01 (Multiple myeloma in remission)
• C90.02 (Multiple myeloma in relapse)

“The documentation provided does not specify if the multiple myeloma is in remission or relapse, so C90.00 is the correct code,” Connell says.