Don’t Forget the 7th Character to Report the Treatment Stage
Question: A patient presented for an MRI exam without contrast of their right knee. The patient complained of knee locking and medial joint line pain for approximately six weeks. The radiologist performed the MRI and reviewed the images. The documented diagnosis lists a complex tear of the medial meniscus; the lateral meniscus was intact, and the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are intact. How do I report the diagnosis? New Mexico Subscriber Answer: Assign S83.231A (Complex tear of medial meniscus, current injury, right knee, initial encounter) to report the complex tear of the medial meniscus in the right knee. This code requires a 7th character to indicate the encounter type. The 7th character “A” shows that the patient is seeking active treatment for the injury. Bonus: You’ll also use 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material) to report the MRI of the right knee. Append modifier RT (Right side) to the CPT® code to show that the radiologist performed the procedure on the right side of the body. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
