I am new to radiology coding, and I'm having trouble making the shift from the cut-and-dried dx coding in chart notes to the not-so-overt diagnoses listed as a radiologist's impressions. I can use an opinion or 2 or 3 from others more experienced than I. Please read the following and let me know how you would code the diagnoses. Feel free to give me as much or as little explanation as you wish. (Do all radiology reports typically read like this?)
Indications:
Low back pain radiating down both lower legs. Clinical concern for degenerative intervertebral disc disease.
Impressions:
1) T11/T12: 7 mm right forminal nerve root sleeve diverticulum is present. Mild right dorsal lateral thecal sac effacement is also present related to ligamentum flavum hypertrophy.
2) L4-L5: Mild loss of disc space height and disc dessication is present. There is a focal tear in the outer 3rd periphery of the central posterior annulus fibrosis at the site of a 3 mm disc protrusion that causes mild central canal stenosis. In the left lateral recess, there is nerve root sleeve effacement and encroachment on the budding left L5 nerve root. In the right lateral recess, there is nerve root sleeve effacement and abutment of the budding right L5 nerve root. Mild Synovial fluid lines both facet joints. Mild left neural foraminal narrowing is present.
3) L5-S1: Mild left facet arthropathy.
All answers and info are greatly appreciated!
Indications:
Low back pain radiating down both lower legs. Clinical concern for degenerative intervertebral disc disease.
Impressions:
1) T11/T12: 7 mm right forminal nerve root sleeve diverticulum is present. Mild right dorsal lateral thecal sac effacement is also present related to ligamentum flavum hypertrophy.
2) L4-L5: Mild loss of disc space height and disc dessication is present. There is a focal tear in the outer 3rd periphery of the central posterior annulus fibrosis at the site of a 3 mm disc protrusion that causes mild central canal stenosis. In the left lateral recess, there is nerve root sleeve effacement and encroachment on the budding left L5 nerve root. In the right lateral recess, there is nerve root sleeve effacement and abutment of the budding right L5 nerve root. Mild Synovial fluid lines both facet joints. Mild left neural foraminal narrowing is present.
3) L5-S1: Mild left facet arthropathy.
All answers and info are greatly appreciated!
