Radiology Coding Alert

Pay attention to region and contrast for accurate coding.

The spine is one of the most crucial body parts in the body as it gives the body structure, allows for flexible movement, and houses the nerves as they run from the brain to the rest of the body. If patients start to experience symptoms suddenly, their healthcare provider may need to use an MRI to visualize the spinal cord to evaluate the various components.

Read on to learn about the spine and how to accurately report spinal MRI codes.

Analyze the Spinal Cord Anatomy

The spine is made up of facet joints, intervertebral discs, spinal cord and nerves, soft tissues, and 33 vertebrae to give the body shape, support, and allow the patient to move. The spine features five distinct segments — cervical spine, thoracic spine, lumbar spine, sacrum, and coccyx.

The cervical spine has seven vertebrae (C1-C7) that are located in the neck. The bones let the patient tilt, turn, and nod the head. The middle back is home to the thoracic spine, which has 12 vertebrae (T1-T12). The thoracic spine attaches to the ribs. Beneath the thoracic spine is the lumbar spine, which has five vertebrae (L1-L5). The lumbar spine vertebrae are larger than the cervical and thoracic vertebrae because the lumbar spine carries the brunt of the body’s weight.

Connecting to the patient’s hips is the sacrum, which is a triangle-shaped bone made of five vertebrae (S1-S5). The sacral vertebrae fuse together during fetal development, so they don’t move like C1-L5. Finally, the coccyx is made up of four fused vertebrae at the bottom of the spine.

Due to its role in the patient’s daily life, the spine can be at the center of several conditions. Common conditions affecting the spine include, but are not limited to:

• Bone spurs
• Herniated discs
• Osteoporosis
• Fractures
• Infections

Before the physician definitively diagnoses the patient’s condition, the patient may experience any number of signs and symptoms that would warrant an imaging exam to evaluate the patient. The most common symptoms of a spinal condition include:

• Back pain
• Neck pain
• Numbness in the extremities
• Muscle spasms

Familiarize Yourself With the MRI Codes

Depending on the patient’s symptoms, the physician may order an MRI of the spine for evaluation in greater detail. The CPT^® code book includes several codes to report spinal MRI procedures. The codes differ in the area of the spine that is imaged and whether the provider used contrast material to enhance the body structures imaged.

Select from the following codes for an MRI of the cervical spine:

• 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material)
• 72142 (… with contrast material(s))

Look to the codes below for an MRI of the thoracic spine:

• 72146 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material)
• 72147 (… with contrast material(s))

MRI of the lumbar spine codes include:

• 72148 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material)
• 72149 (… with contrast material(s))

When the radiologist performs an MRI of the spinal canal and its contents, first without contrast and then administers contrast and captures additional images, you’ll select from the following codes:

• 72156 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical)
• 72157 (… thoracic)
• 72158 (… lumbar)

Examine These Coding Scenarios

Scenario 1: A 75-year-old patient is experiencing neck pain and numbness in the hands. An MRI of the cervical spine without and with contrast is ordered. The radiologist documents cervical disc degeneration at C4 through C6.

Assign 72156 to report the cervical spine MRI without contrast followed by contrast administration and additional images. You’ll also use M50.321 (Other cervical disc degeneration at C4-C5 level) and M50.322 (Other cervical disc degeneration at C5-C6 level) to report the cervical disc degeneration.

Scenario 2: A radiologist performs an MRI spine survey without contrast on a patient after the patient was struck by a vehicle. The radiologist documents their findings as traumatic stable burst fractures of the T12 to L3 vertebrae.

An MRI spine survey is also known as a total spine MRI. The CPT^® code book currently does not designate a code for an MRI of the complete spine, so you’ll need to report the individual codes that reflect each region of the spine. In this scenario, you’ll report 72141, 72146, and 72148. This is the most appropriate approach when the radiologist performs and interprets an MRI of all three regions. You should also make sure the radiologist documented separate reports for each separate region studied.

Use the following ICD-10-CM codes to report the traumatic stable burst fractures of the T12 through L3 vertebrae:

• S22.081A (Stable burst fracture of T11-T12 vertebra, initial encounter for closed fracture)
• S32.011A (Stable burst fracture of first lumbar vertebra, initial encounter for closed fracture)
• S32.021A (Stable burst fracture of second lumbar vertebra, initial encounter for closed fracture)
• S32.031A (Stable burst fracture of third lumbar vertebra, initial encounter for closed fracture)

A stable burst fracture of the vertebra refers to a break in the bony portion of the spine, usually as a result of a severe high-impact trauma. While the patient suffered a traumatic injury, they didn’t experience any neurologic injury and minimal spinal canal compromise.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC