Radiology Coding Alert

Reader Questions:

Master MRI Coding of a Brachial Plexus Injury

Published on Wed Apr 20, 2022

Question: A 24-year-old patient with a history of playing football presented to our radiology practice for a magnetic resonance imaging (MRI) scan without contrast of their right shoulder girdle. The patient claims to have experienced an electric shock down their arm originally, and now they’re experiencing weakness in their right hand. The radiologist performed the MRI and reported their diagnosis of a brachial plexus injury.

How do I report the procedure?

Wisconsin Subscriber

Answer: You’ll assign 73218 (Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)) to report the MRI of the patient’s shoulder girdle.

The brachial plexus is a neural network that sends signals from the spinal cord to the shoulder, arm, and hand. The patient experiences a brachial plexus injury if the nerves become stretched, compressed, or rip apart from the spinal cord. Symptoms of minor injuries include stingers or burners, which are common injuries from playing contact sports, like football. More severe brachial plexus injuries from motor vehicle accidents (MVAs) could cause arm paralysis.

You noted in your question that the patient initially felt an electric shock but is now presenting weakness in their hand. This is consistent with a brachial plexus injury, which the radiologist diagnosed in their report. You’ll assign S14.3XXA (Injury of brachial plexus, initial encounter) to report the patient’s diagnosis.