Radiology Coding Alert

You Be the Coder:

Do Not Include Degenerative Diagnoses with Trauma Indications

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 [...]
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