Practice Report

Practice Report To Code

Here is a practice diagnostic radiology report to code. Code the ICD-10-CM and CPT. Please put your answers in the comment section. If you have any questions, please feel free to email me at midnightmedicalcoding@gmail.com

 

Exam: MRI lumbar spine w/o contrast

History: Lumbar back pain

Technique: MRI of the lumbar spine was performed w/o contrast on a tesla.

Comparison: None

Findings: L1-L2- Annular disc bulge with osteophyte formation consistent with osteoarthritis. L2-L3- Endplate osteophyte formation. L3-L4- Loss of disc space height and moderate central canal stenosis. L4-L5- no disc protrusion. No central canal stenosis.

Impression: Osteoarthritis of the lumbar spine without myelopathy or radiculopathy.

Thank you for referring your patient.

 

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