Radiology Coding Alert

Question: A patient presented to an outpatient radiology practice with sharp pain in their left foot. The patient’s general practitioner (GP) referred the patient to receive X-rays on the foot. The radiologist captured anteroposterior (AP), lateral, and transverse views and issued their impression as “fractures of the 2+3 L metatarsal.” However, the findings are listed as a march fracture of the left foot.

What codes should I report for this encounter?

North Carolina Subscriber

Answer: You’ll need one CPT^® code and one ICD-10-CM code to report this encounter. Starting with the procedure code, you’ll assign 73630 (Radiologic examination, foot; complete, minimum of 3 views) to report the three-view X-rays. Check with your individual payer preferences to confirm if the payer requires a laterality modifier, such as LT (Left side), to indicate that the radiologist captured X-rays on the left side of the patient’s body.

The march fracture diagnosis is coded using M84.375A (Stress fracture, left foot, initial encounter for fracture). A march fracture occurs when the metatarsals are subjected to repetitive impacts with weight-bearing exercises, such as marching. The repeated impacts can cause microfractures that contribute to a stress fracture.

When you search the ICD-10-CM Alphabetic Index for Fracture, traumatic > march, you’ll find a note directing you to Fracture, traumatic > stress > by site. “By site” means to locate the body structure which is affected by the stress fracture and verify that code in the Tabular List. In your case, you’ll look to the metatarsus subcategory to locate the correct code.

In the ICD-10-CM code set, march fracture is a synonym for M84.3- (Stress fracture), so you’ll know to assign an applicable stress fracture code if you see the term “march fracture” on the radiology report or encounter notes.