Radiology Coding Alert

Question: I have a report that indicates the radiologist captured three X-ray views of the patient’s thoracolumbar junction. The patient presented to the imaging facility with low-to-mid back pain. The provider evaluated the X-rays and found disc degeneration as well as a T12-L1 spinal fusion.

I don’t see a reference in the patient history of a previous spinal fusion surgery. How do I code the spinal fusion diagnosis?

Alaska Subscriber

Answer: You are safe to consider the T12-L1 fusion to be congenital if the report doesn’t reference a prior arthrodesis procedure. In this scenario, you’ll assign M51.35 (Other intervertebral disc degeneration, thoracolumbar region) for the disc degeneration and M43.25 (Fusion of spine, thoracolumbar region) to report the T12-L1 congenital spinal fusion.

Keep in mind that a congenital spinal fusion may or may not be relevant to your report. For example, if the patient visited your facility presenting symptoms of back pain following a traumatic event, such as a car accident, and the provider finds a herniated disk at the T10-T11 spine, you shouldn’t use congenital spinal fusion as a secondary diagnosis — actually, you won’t report the spinal fusion at all.

However, if the provider examines the images and determines the presence of spinal degeneration absent of trauma, such as in your question, then you may consider including M43.25 on your report as a secondary diagnosis.