Radiology Coding Alert

Question: Which ICD-9 Code should I use for a report that says: Mild central disk bulge at L4-L5 with facet and ligamentum flavum hypertrophy?

Oklahoma Subscriber

Answer: Your best bet is 722.10 (Displacement of thoracic or lumbar intervertebral disc without myelopathy; lumbar intervertebral disc without myelopathy) with 724.8 (Other symptoms referable to back) to indicate the spinal ligament hypertrophy.

Here’s why: The documented "mild central disc bulge" indicates disc displacement. The bulge is at L4-5, and L indicates lumbar.

You should choose a "without myelopathy" code because the documentation does not explicitly state "with myelopathy" (a spinal cord disorder). You should report myelopathy only if the referring physician documents it, because myelopathy is a clinical finding -- not an image finding.

If the history or exam request does indicate myelopathy, you should report 722.73 (Intervertebral disc disorder with myelopathy; lumbar region).