Radiology Coding Alert

Question: A patient presented to our radiology practice with pain and swelling in the right knee. The patient was referred by their primary care physician (PCP) for MRI of the knee. The radiologist performed the MRI without contrast and with contrast, and then reviewed the images. The findings are listed as an anterior cruciate ligament (ACL) tear.

What codes will I use for this encounter?

New York Subscriber

Answer: Use 73723 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences) to report the MRI of the knee. This code covers the radiologist capturing images without contrast, administering contrast, and then capturing additional images with contrast.

Remember: According to CPT^® guidelines, “with contrast” imaging procedure codes “represents contrast material administered intravascularly, intra-articularly, or intrathecally.” This means that if the documentation mentions the contrast isn’t administered into the blood vessel (intravascularly), into the joint space (intra-articularly), or into the spaces of the spinal cord (intrathecally), then you cannot report a “with contrast” code.

Next, you’ll turn to the ICD-10-CM code book for the diagnosis code. In the Alphabetic Index, you’ll find Laceration > ligament directs you to Sprain. Under Sprain (joint) (ligament), follow the indentations to knee, then cruciate ligament, and finally anterior, which refers you to S83.51- (Sprain of anterior cruciate ligament of knee).

Turn to the Tabular List, where you’ll find that S83.51- requires 6^th and 7^th characters to complete the code. The 6^th character specifies laterality, while the 7^th character indicates the type of encounter. Use S83.511A (Sprain of anterior cruciate ligament of right knee, initial encounter) to report the right knee ACL tear.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC