Radiology Coding Alert

Question: I have a report from an urgent care facility that indicates a radiologist performed a computed tomography (CT) scan without contrast on the abdomen and pelvis of a patient who experienced a splenic injury. The report lists the injury as a 3 cm parenchymal laceration of the right spleen with hypovolemia based on the small caliber of the inferior vena cava (IVC). There is no evidence of lower thoracic or lumbar spine fractures.

What CPT^® and ICD-10-CM codes should I assign to my report?

Montana Subscriber

Answer: Starting with the CT scan, you’ll assign 74176 (Computed tomography, abdomen and pelvis; without contrast material) since the abdomen and pelvis were examined without the use of contrast material by the radiologist.

Next, you’ll need to assign S36.031A (Moderate laceration of spleen, initial encounter) and E86.1 (Hypovolemia) for the diagnoses.

To locate the splenic laceration code, look for Laceration > spleen > moderate S36.031- (Moderate laceration of spleen) in the ICD-10-CM Alphabetic Index. When you verify the code in the tabular list, you’ll find a note under the descriptor for S36.031- that defines a moderate laceration of the spleen as cut measuring 1 to 3 cm. Code S36.031- also requires a 7th character. Since the patient presented to an urgent care facility, you’ll assign A to specify this was an initial encounter and they underwent active treatment for the injury.

Hypovolemia is a condition where the plasma of the patient’s blood is too low. Return to the Alphabetic Index and search for Hypovolemia, which provides you with E86.1. When you verify the code in the tabular list, you’ll find an additional synonym of “Depletion of volume of plasma.”