Radiology Coding Alert

Question: A patient presented to an outpatient radiology practice for a computed tomography (CT) scan of their abdominal wall with contrast. The patient was recently diagnosed via biopsy with a Desmoid tumor of the abdominal wall, and the CT scan was ordered to evaluate the size and location of the tumor.

What codes will I use for the encounter?

Washington Subscriber

Answer: Select 74160 (Computed tomography, abdomen; with contrast material(s)) to report the CT scan of the abdominal wall with contrast. Typically, the CT scan captures cross-sectional images of the patient’s abdomen, so the physician can use the views to diagnose and treat the patient’s condition. In your situation, the provider ordered the CT scan to assess the exact location and size of the Desmoid tumor.

Next, you’ll turn to the ICD-10-CM code set to locate the correct Desmoid tumor diagnosis code. In the ICD-10-CM Alphabetic Index, look for Tumor > desmoid > abdominal, which directs you to Neoplasm > connective tissue > uncertain behavior. You’ll be redirected to the Table of Neoplasms when you search the Alphabetic Index for Neoplasm.

In the Table of Neoplasms, look for connective tissue > abdominal wall and search across until you reach the Uncertain Behavior column, which provides you with D48.1- (Neoplasm of uncertain behavior of connective and other soft tissue). Turn to the Tabular List to verify the code where you’ll discover the D48.11- (Desmoid tumor) code subcategory, which requires a 6th character to complete the code. In your case, D48.113 (Desmoid tumor of abdominal wall) is the correct code for the patient’s diagnosis.