Radiology Coding Alert

Question: I’m working on a patient who’s had a lumbar spine X-ray and a lumbar spine magnetic resonance imaging (MRI) scan on the same day. The lumbar X-ray documents L1 and L2 compression fractures in the impression with radiculopathy documented in the indication. The MRI, however, documents the same compression fractures in the impression, but states trauma in the indication. Should I code the X-ray diagnoses as non-traumatic?

Rhode Island Subscriber

Answer: As you are well aware, if you code each report with what’s documented in the indication, you will come up with two entirely different diagnosis codes. Since you code spinal compression fractures separately depending on whether they are trauma-induced or pathological, you would end up reporting M48.56XA (Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture) for the X-ray and codes S32.010A (Wedge compression fracture of first lumbar vertebra, initial encounter for closed fracture) and S32.020A (Wedge compression fracture of second lumbar vertebra, initial encounter for closed fracture) for the MRI.

Since these two exams are clearly related, it’s safe to assume that you need to revise one of these two indicating diagnoses. It’s likely that trauma is the underlying reason for the patient’s visit to the radiology department, but you should confirm with the provider before submitting either exam to insurance. If and when the provider confirms the visit is trauma-related, you should request an addendum on the lumbar spine X-ray to include a reference to the underlying trauma. At that point, you can submit both claims with the same diagnoses of S32.010A and S32.020A.