Radiology Coding Alert

Question: A patient is scheduled to receive a CT maxillofacial without contrast for an apparent mass within the nasal cavity. The radiologist does not identify a mass on the scan, but does not rule out the possibility of the mass due to motion artifact blurring the exam. Should I code both the mass and the headache, since it's not clear that the migraine is the result of the mass?

Utah Subscriber

Answer: Due to a lack of any definitive findings in the impression, you will refer back to the indication for the diagnosis coding. Even though the provider does not identify the mass, it's also not ruled out due to motion artifact. Unless the mass is definitively stated as absent by the radiologist - or another conclusive finding is documented in the impression that explains the nasal mass diagnosis - you should code the mass as the primary diagnosis.

Since the physician did not detail the location of the mass, your diagnostic coding options are somewhat limited. In this case, however, you will rely on the same code whether or not the physician documents the mass as within a particular sinus or, simply, the nasal cavity. Due to the lack of specificity of both location and the behavior of the mass, you will opt for the diagnosis code J34.9 (Unspecified disorder of nose and nasal sinuses).