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? Dx code

  1. #1
    Default ? Dx code
    Medical Coding Books
    Pt had an MRI T-spine w/wo... order states T-SPINE MASS


    The previously seen left paraspinal cystic mass at the approximate T9 level is again noted. Again, this measure approximately 1.5 x 1.0 cm in size and is not changed and again, does not appear to enhance. This is believed to be some stable, benign, possibly developmental cystic lesion. There are no focal osseous abnormalities. There is no intradural enhancement or lesion. The spine is midly scoliotic. There is no evidence of frank disc herniation or spinal stenosis. There are some minmal bulging discs throughout the thoracic spine again noted but these are stable.

    IMPRESSION: stable left paraspinal unenhancing, benign-appearing cystic lesion at the T9 level. No new abnormality


    Kimberley Tober, CPC
    Franklin, TN

  2. Default
    It would be helpful to know what you have considered and ruled out. I would suggest Cyst, bone, solitary 733.21. Hope this helps.

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