Radiology Coding Alert

Question: I am working on a report for a DEXA bone scan. The physician lists osteoporosis in the indication, but the impression only states low bone mass of the lumbar spine and hip. What ICD-10 code(s) should I use to document this? Also, should I apply a screening code?

California Subscriber

Answer: This is one of those scenarios where the indication contradicts what’s reported in the impression. In circumstances where the indication and impression differ, always opt for the impression as the overriding diagnosis.

There’s much to unpack in this question before coming to a determination of the right diagnosis. Knowing that the impression trumps the indication in this situation, we can disregard the indicating diagnosis entirely when applying the correct ICD-10 code(s). Some coders believe that a screening code should always be applied to a dual-energy X-ray absorptiometry (DEXA) scan, however if the term “screening” is not specifically stated in the indication, there is no justification in using Z13.820 (Encounter for screening for osteoporosis) as a secondary diagnosis code.

“Many times, the indication will differ from the impression,” states Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “The indication for the procedure may list symptoms, but the impression should have a definitive diagnosis. If there is no diagnosis—only in that case is it acceptable to code what is in the indication.”

Rationale: “The ICD-10-CM coding guidelines state: ‘Codes that describe symptoms and signs as opposed to diagnoses are acceptable for reporting purposes when a related, definitive diagnosis has not been established (confirmed) by the provider,’” Della Vella relays. “It’s also important for radiologists to have clear documentation in the reports. The indication should never be written as a rule out (example: ‘rule out’ pneumonia) because, according to ICD-10, that is not a valid diagnosis. It should be worded to the symptoms if no valid diagnosis is present.”

The second issue we come across with this question is the inability to definitively apply a diagnosis to the term “low bone mass.” As this is an unindexable diagnosis, we’ll have to opt for an alternative route in coming to the correct diagnosis. According to the New York State Department of Health, low bone mass can be interchangeably used with the medical diagnosis of osteopenia. Knowing that osteopenia correlates to ICD-10 code M85.8X (Other specified disorders of bone density and structure), we then have to determine whether a fifth digit can account for osteopenia of both the hip and lumbar spine. We see that the code M85.89 (Other specified disorders of bone density and structure, multiple sites) fits the diagnosis we are looking for. The correct (and only) ICD-10 code to apply in this circumstance is M85.89.

What if: How about a scenario where the only documented diagnosis was osteopenia of the hip? This is another one of those grey areas when it comes to ICD-10 coding. Coders typically tend to wrestle between M85.85X (Other specified disorders of bone density and structure, right/left thigh) or M85.88 (Other specified disorders of bone density and structure, other site). While a coder might be inclined to consider the femur and hip the same anatomical site, that is not necessarily the case. Since the anatomy of the hip actually includes the femoral head, the pelvis, and the acetabulum, a case can be made that there is enough ambiguity here to err on the side of caution and apply code M85.88.