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Question: A 45-year-old patient presented to the radiology clinic with lower right leg pain. The patient is an avid runner and was playing pickleball when the injury occurred. The radiologist performed an MRI examination without contrast of the right leg between the knee and the ankle, excluding the joints. The imaging revealed a partially torn calf muscle, which was documented as the diagnosis.

What codes should I report?

Massachusetts Subscriber

Answer: You’ll assign 73718 (Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)) to report the MRI without contrast of the patient’s lower leg. You noted the radiologist imaged the patient’s lower right leg without the knee and ankle joints.

Use S86.821A (Laceration of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter) to report the tear of the patient’s calf muscle on the right leg. Locating the correct diagnosis code can be a bit tricky. In the Alphabetic Index, search for Injury > muscle > leg (lower) > specified > site NEC > laceration, leading you to S86.82- (Laceration of other muscle(s) and tendon(s) at lower leg level), which you’ll verify in the Tabular List.

Code S86.82- requires seven characters to complete the code. The 6^th character “1” specifies the right leg, and the 7^th character “A” indicates the patient is seeking active care for the injury.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC