CPT Code 62290: Discography, lumbar, single or multiple levels, radiological supervision and interpretation
This code accurately describes the procedure performed. The documentation indicates a lumbar discography was performed at a single level (L3-4) with radiological supervision (C-arm visualization).
ICD-10-CM Code M54.50: Low back pain, unspecified
This code is the most appropriate diagnosis based on the documentation. The preoperative diagnosis states "Low back pain possible spinal stenosis L3-4." While spinal stenosis was considered, it was not confirmed. The postoperative diagnosis indicates no evidence of spinal stenosis or discogenic pathology. Therefore, the definitive diagnosis is low back pain.
Why other options are incorrect:
62292: This code is for a discography with injection of contrast and/or medication for therapeutic purposes. The documentation doesn't indicate any therapeutic injection was performed.
M48.061 and M48.07: These codes represent spinal stenosis, which was not confirmed in the postoperative diagnosis.
[References:, CPT Code 62290: Discography, lumbar, single or multiple levels, radiological supervision and interpretation, ICD-10-CM Code M54.50: Low back pain, unspecified, AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures., , , , ]
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