Radiology Coding Alert

Question: A patient presented to the hospital with lumbago where they underwent an MRI of their lumbar spine without contrast material. Following review of the images, the radiologist issued their findings as mild anterior wedging of the L4 vertebral body, severe left paracentral disc protrusion at L2-3, and multilevel degenerative disc disease.

I’ve been coding for many years, but I recently transitioned to radiology coding. How should I report this encounter?

Pennsylvania Subscriber

Answer: Starting with the procedure, you’ll assign 72148 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material) to report the magnetic resonance imaging (MRI) without contrast of the patient’s lumbar spine.

Next, you’ll turn to your ICD-10-CM code set to determine which diagnosis codes to assign.

You’ll assign M48.56XA (Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture) to report the mild anterior wedging of the L4 vertebral body. Vertebral wedging is considered osteoporosis. Look for Wedge-shaped or wedging vertebra in the ICD-10-CM Alphabetic Index, where you’re directed to view Collapse, vertebra NEC. Turning to Collapse > vertebra > lumbar region, you’ll find M48.56 (Collapsed vertebra, not elsewhere classified, lumbar region). When you verify the code in the tabular list, you’ll notice M48.56 requires a 6th character placeholder X and a 7th character to complete the code. You’ll use “A” as the 7th character to indicate the initial encounter.

You’ll then assign M51.26 (Other intervertebral disc displacement, lumbar region) to report the L2-3 severe left paracentral disc protrusion diagnosis. Lastly, you’ll assign M51.36 (Other intervertebral disc degeneration, lumbar region) for the multilevel degenerative disc disease diagnosis.

In summary, you’ll assign the following codes for the encounter:

CPT®: 72148
ICD-10-CM: M48.56XA, M51.26, M51.36