Radiology Coding Alert

Question: A patient receives a CT scan of the lumbar spine after trauma from a fall. The provider documents a fracture of the L2 vertebrae in addition to spondylosis and spondy­lolisthesis of the L3-L4 joint. I coded this encounter as S32.209A, M47.816, and M46.16. Is this correct?

Texas Subscriber

Answer: The indicating diagnosis, also known as the presenting diagnosis, plays a very important role in determining the correct ICD-10 code(s). Often, a coder might disregard the indicating diagnosis entirely and exclusively code the diagnoses the provider documents in the impression.

In this example, since the patient presents for a CT scan of the lumbar spine due to trauma, you will be looking for diagnoses in the findings and impression that may associate with or be a result of trauma. You are correct to code S32.029A (Unspecified fracture of second lumbar vertebra, initial encounter for closed fracture) as the primary diagnosis. The other two diagnoses, however, are irrelevant to the reason the patient is receiving the imaging. The diagnoses M47.816 (Spondylosis without myelopathy or radiculopathy, lumbar region) and M43.16 (Spondylolisthesis, lumbar region) are degenerative in nature. Unless the provider clearly states that these two diagnoses are associated with the trauma, you will not include them.

If you were to bill this procedure with all three diagnoses, you would be committing a form of diagnostic upcoding in which you would be including more diagnoses than are relevant and necessary.