Radiology Coding Alert

Question: I have a report that indicates a radiologist performed magnetic resonance imaging (MRI) of a 70-year-old patient’s prostate before and after intravenous (IV) contrast administration. The radiologist reviewed the images and compiled their report. The impression lists mild prostate enlargement with BPH.

What codes will I assign for the encounter?

Louisiana Subscriber

Answer: You’ll assign 72197 (Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences) to report the MRI of the prostate and N40.0 (Benign prostatic hyperplasia without lower urinary tract symptoms) for the diagnosis listed in the report.

In the CPT^® code set Index, look for Magnetic Resonance Imaging (MRI) > Diagnostic > Pelvis, which provides you with the 72195-72197 (Magnetic resonance (eg, proton) imaging, pelvis …) code range. When you turn to the Radiology section to select your code, you’ll find that 72197 is the most appropriate code for the procedure because it includes the MRI of the patient’s pelvis without contrast material followed by further scans with contrast material.

There isn’t an MRI code that specifically images the prostate, so you need to use the procedure code that images the area around the prostate. In this case, that area is the pelvis.

The radiologist’s report listed mild prostate enlargement with benign prostatic hyperplasia (BPH) under the impression. Open the ICD-10-CM Alphabetic Index and search for Hypertrophy > prostate > benign, which redirects you to Enlargement, enlarged, prostate. Under Enlargement, look for prostate > without lower urinary tract symptoms (LUTS) to find N40.0. You’ll then verify the code in the Tabular List.

Includes note: Parent code N40.- (Benign prostatic hyperplasia) also features an Includes note that contains “enlarged prostate” and “BPH.”