Radiology Coding Alert

Question: I have a report for an emergency department (ED) encounter. A 7-year-old patient was brought into the ED with right upper arm pain following a car accident. The provider captured AP, PA, and lateral X-ray views of the patient’s right humerus. After reviewing the images, the radiologist didn’t find any fractures, dislocations, or other abnormalities.

What codes will I assign for this encounter?

Ohio Subscriber

Answer: You’ll assign one CPT^® and one ICD-10-CM code for this encounter. Starting with the procedure code, you’ll assign 73060 (Radiologic examination; humerus, minimum of 2 views) to report the three-view X-ray procedure. You indicated the radiologist captured anteroposterior (AP), posteroanterior (PA), and lateral views of the patient’s right humerus. The three views fulfill the imaging requirements for 73060.

Next, you’ll open your ICD-10-CM code set to find the diagnosis code. In this case, you’ll assign M79.621 (Pain in right upper arm). The patient presented to the emergency department (ED) with right upper arm pain, but no fractures, dislocations, or other conditions were observed in the X-rays. Since the X-ray results were normal, you’ll code the symptom the patient was experiencing.

Look for Pain in the ICD-10-CM Alphabetic Index and follow the indentations to limb > upper > upper arm, which provides you with M79.62- (Pain in upper arm). When you verify the code in the Tabular List, you’ll find a 6th character required icon, which is needed to indicate laterality.