Radiology Coding Alert

Question: I have a radiology report following a computed tomography (CT) scan with contrast that lists the diagnosis as radiculopathy in the thoracolumbar spine region. We assigned M54.15 and M54.16 as the diagnosis codes, but the claim was denied.

How can we correct the claim?

Florida Subscriber

Answer: You only need to assign M54.15 (Radiculopathy, thoracolumbar region) instead of reporting both M54.15 and M54.16 (Radiculopathy, lumbar region).

The provider diagnosed the patient with radiculopathy in the thoracolumbar spine, which covers the thoracic and lumbar regions. Code M54.15 specifies both the thoracic and lumbar areas, which makes reporting M54.16 for the lumbar region redundant.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC