Chapter 17: Practical Application
Location: Imaging center, radiologist employed. (Radiologist is employed by the imaging center:
the imaging center should report the global component.)
STUDY: FEMUR AP AND LATERAL(2 views taken.)
REASON: LEFT LEG PAIN
LEFT FEMUR:
COMPARISON: There are no prior studies for comparison.
FINDINGS: There is no fracture or dislocation of the left femur. The femoral head is
concentrically seated within the acetabulum without deformity of the femoral head.
IMPRESSION: Normal (Findings are normal, the reason for the study is used for the diagnosis.)
views of the left femur.
What are the CPT® and ICD-10-CM codes reported for this service? - Answer 73552-LT
M79.605
Response Feedback:
There is one CPT® code and one ICD-10-CM code reported. An AP and lateral X-ray of the femur
is performed at an outpatient hospital. The radiologist is employed by the hospital. When
reading documentation of ANY radiology report, it is imperative to ascertain how many views of
each body part were obtained as indicated in the Study. Use a HCPCS Level II modifier to
indicate the side X-rayed. Look in the CPT® Index for X-ray/Femur for the code range. If the
Impression is normal, the reason for the study is the reported diagnosis. In the ICD-10-CM
Alphabetic Index look for Pain(s)/leg and referring you to see Pain, limb, lower.
Location: Regional Hospital(The hospital will report the technical component. Only the
professional component should be reported.)
MRI OF THE LUMBAR SPINE
History: Low back pain.(Reason for the MRI, also known as Lumbago.)
, Technique: On a 1.5 Tesla magnet multiple sagittal and axial(Sagittal and axial images were
taken.) images were performed through the lumbar spine(Location—lumbar spine.) using
variable pulse sequences.
Findings: There is normal lumbar alignment. The conus is in normal position at the
thoracolumbar junction. No suspect bone marrow lesions are present. There is mild anterior
wedging of the L3 vertebral body. I am uncertain whether this is an acute or chronic finding.
At the T12-L1 level, there is a small posterior disc bulge. There is no central canal stenosis. There
is no neural foraminal stenosis.
At the L1-2 level, there is no disc bulge or protrusion. There is no central canal or neural -
Answer Answer for: a
72148-26
Specified Answer for: b
M48.56XA
Specified Answer for: c
M51.26
Specified Answer for: d
M51.36
Response Feedback:
There is one CPT® code and three ICD-10-CM codes. An MRI (Magnetic Resonance Imaging) of
the lumbar spine without contrast is performed at the Regional Hospital. The radiologist is not
employed by the hospital. The professional component modifier is reported. In the CPT® Index
locate Magnetic Resonance Imaging (MRI)/Diagnostic/Spine/Lumbar for the code range. The
radiologist's findings are indicated in the Impression of the report. There is "wedging of the L3
vertebral body" as the first diagnosis. In the ICD-10-CM Alphabetic Index look for Wedge-shaped
or wedging vertebra directing you to see Collapse, vertebra/lumbar region. The second
diagnosis is paracentral disc protrusion at L4-L5. Locate Protrusion/intervertebral referring you
to see Displacement/intervertebral disc NEC/lumbar region. The last diagnosis is multilevel
degenerative disc disease. Look in the Alphabetic Index for Degeneration/intervertebral
disc/lumbar region.
Location: Imaging center; radiologist employed.(Radiologist is employed by the imaging center:
the imaging center should report the global component.)
STUDY: MAMMOGRAM BILATERAL SCREENING,(Screening bilateral mammogram.) all VIEWS,
PRODUCING DIRECT DIGITAL IMAGE
REASON: SCREEN
Location: Imaging center, radiologist employed. (Radiologist is employed by the imaging center:
the imaging center should report the global component.)
STUDY: FEMUR AP AND LATERAL(2 views taken.)
REASON: LEFT LEG PAIN
LEFT FEMUR:
COMPARISON: There are no prior studies for comparison.
FINDINGS: There is no fracture or dislocation of the left femur. The femoral head is
concentrically seated within the acetabulum without deformity of the femoral head.
IMPRESSION: Normal (Findings are normal, the reason for the study is used for the diagnosis.)
views of the left femur.
What are the CPT® and ICD-10-CM codes reported for this service? - Answer 73552-LT
M79.605
Response Feedback:
There is one CPT® code and one ICD-10-CM code reported. An AP and lateral X-ray of the femur
is performed at an outpatient hospital. The radiologist is employed by the hospital. When
reading documentation of ANY radiology report, it is imperative to ascertain how many views of
each body part were obtained as indicated in the Study. Use a HCPCS Level II modifier to
indicate the side X-rayed. Look in the CPT® Index for X-ray/Femur for the code range. If the
Impression is normal, the reason for the study is the reported diagnosis. In the ICD-10-CM
Alphabetic Index look for Pain(s)/leg and referring you to see Pain, limb, lower.
Location: Regional Hospital(The hospital will report the technical component. Only the
professional component should be reported.)
MRI OF THE LUMBAR SPINE
History: Low back pain.(Reason for the MRI, also known as Lumbago.)
, Technique: On a 1.5 Tesla magnet multiple sagittal and axial(Sagittal and axial images were
taken.) images were performed through the lumbar spine(Location—lumbar spine.) using
variable pulse sequences.
Findings: There is normal lumbar alignment. The conus is in normal position at the
thoracolumbar junction. No suspect bone marrow lesions are present. There is mild anterior
wedging of the L3 vertebral body. I am uncertain whether this is an acute or chronic finding.
At the T12-L1 level, there is a small posterior disc bulge. There is no central canal stenosis. There
is no neural foraminal stenosis.
At the L1-2 level, there is no disc bulge or protrusion. There is no central canal or neural -
Answer Answer for: a
72148-26
Specified Answer for: b
M48.56XA
Specified Answer for: c
M51.26
Specified Answer for: d
M51.36
Response Feedback:
There is one CPT® code and three ICD-10-CM codes. An MRI (Magnetic Resonance Imaging) of
the lumbar spine without contrast is performed at the Regional Hospital. The radiologist is not
employed by the hospital. The professional component modifier is reported. In the CPT® Index
locate Magnetic Resonance Imaging (MRI)/Diagnostic/Spine/Lumbar for the code range. The
radiologist's findings are indicated in the Impression of the report. There is "wedging of the L3
vertebral body" as the first diagnosis. In the ICD-10-CM Alphabetic Index look for Wedge-shaped
or wedging vertebra directing you to see Collapse, vertebra/lumbar region. The second
diagnosis is paracentral disc protrusion at L4-L5. Locate Protrusion/intervertebral referring you
to see Displacement/intervertebral disc NEC/lumbar region. The last diagnosis is multilevel
degenerative disc disease. Look in the Alphabetic Index for Degeneration/intervertebral
disc/lumbar region.
Location: Imaging center; radiologist employed.(Radiologist is employed by the imaging center:
the imaging center should report the global component.)
STUDY: MAMMOGRAM BILATERAL SCREENING,(Screening bilateral mammogram.) all VIEWS,
PRODUCING DIRECT DIGITAL IMAGE
REASON: SCREEN
