Radiology Coding Alert

Question: A patient came into our practice for a metal clearance screening before their MRI study next week.

What diagnosis code should I assign for the encounter?

Kansas Subscriber

Answer: One option for reporting this encounter is to assign Z01.89 (Encounter for other specified special examinations) as the diagnosis code. This code features a Z-1 icon in the ICD-10-CM code set, which means the code can be used as the primary diagnosis code followed by any additional diagnosis codes.

According to the ICD-10-CM Official Guidelines, Section IV.K, “For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.”

Some patients, like those who frequently work with metal, will undergo the metal clearance prior to a magnetic resonance imaging (MRI) to ensure there aren’t any metal fragments in the body that could affect the MRI equipment.

As always, reviewing your individual payer policies will help ensure you assign the correct code to meet your payer’s preferences.