Radiology Coding Alert

Question: Parents brought their 6-year-old child into the emergency department (ED) following a fall at a local playground. The patient’s parents stated the child went down a slide quickly, was unable to stop themselves at the end, and landed hard on their tailbone. Following a physical evaluation in the ED, the physician ordered X-rays to check for a tailbone fracture. The radiologist captured anteroposterior (AP) and lateral views of the patient’s coccyx. The images were negative for a fracture and the patient was diagnosed with a contusion of the coccyx.

What codes do I need to report?

Kentucky Subscriber

Answer: You’ll need to assign one CPT^® code and two ICD-10-CM codes for your report. You’ll assign 72220 (Radiologic examination, sacrum and coccyx, minimum of 2 views) to report the X-rays of the patient’s tailbone. The coccyx is the small bone at the end of the spine, and it’s commonly known as the tailbone. When you look up X ray > Coccyx in the AMA CPT^® index, you’ll find 72220, which you’ll then verify in the Radiology chapter of the CPT^® code set.

For the diagnosis codes, start with the contusion of the coccyx. In the ICD-10-CM Alphabetic Index, follow the indentations of Contusion > back > lower to find S30.0- (Contusion of lower back and pelvis). When you turn to the tabular list to verify the code, you’ll find S30.0- requires a 7th character to describe the episode of care as initial, subsequent, or sequela. Since the patient was brought into the ED for care, you’ll select 7th character A. Remember, you’ll also need placeholder characters to complete the code, which leads you to S30.0XXA (Contusion of lower back and pelvis, initial encounter).

Next, you may want to document how the patient was injured. In this situation, the parents stated the child fell from a playground slide. For this code, you’ll turn to the External Causes of Injuries where you’ll follow the indentations Fall > from > playground equipment > slide. You’ll then verify the code in the tabular list, where once again, a 7th character and two placeholder characters are needed to complete W09.0XXA (Fall on or from playground slide, initial encounter).

The ICD-10-CM Official Guidelines, Section I.C.20, states there is no national requirement to report activity codes. However, the patient’s payer or state may require the information, or the payer may choose to report an external cause of morbidity code from Chapter 20 to help with data collection.