Radiology Coding Alert

Question: A senior patient presented to a radiology practice with chronic low back pain. The radiologist captured anteroposterior (AP), lateral, and bending views of the patient’s L1-L5 vertebrae. The patient hasn’t experienced any recent trauma. The radiologist’s findings list chronic low back pain due to lumbar spondylolisthesis.

Which condition do I report as the diagnosis?

Oregon Subscriber

Answer: Low back pain is a symptom of spondylolisthesis, so you only need to report M43.16 (Spondylolisthesis, lumbar region) for this diagnosis. Including a low back pain code, such as M54.50 (Low back pain, unspecified), on your claim is unnecessary and incorrect since the radiologist documented a definitive finding of spondylolisthesis.

Lumbar spondylolisthesis occurs naturally over time and with wear and tear on the spinal joints. Other conditions like infections, arthritis, and stress fractures can also cause lumbar spondylolisthesis to develop.

Don’t forget: Subcategory M43.1- (Spondylolisthesis) also features an Excludes1 note referencing the following acute traumatic or congenital condition codes:

• S33.1- (Subluxation and dislocation of lumbar vertebra)
• Q76.2 (Congenital spondylolisthesis)

As mentioned above, spondylolisthesis develops over time as opposed to being an acute condition caused by trauma (coded to S33.1-) or a condition that has been with the patient since birth (coded to Q76.2). The S33.1- Excludes1 note also tells you not to use M43.1- if the condition is described as “acute traumatic of lumbosacral region.” This instruction is considered an unwritten descriptor for S33.1- since the condition isn’t listed within the ICD-10-CM code set in that subcategory.