# stenosis question please?



## BFAITHFUL (Apr 18, 2010)

okay..  dumb question..    if I have an operative report that states  cervical herniated disc at C4-C5 with stenosis....       I know  for herniation it's 722.0 but if the stenosis is not further specificed as foraminal or spinal,  then I should not code it right?


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## rkmcoder (Apr 19, 2010)

(These are my opinions and should not be construed as being the final authority.  Other opinions may vary.)

If you look at the 724 codes in your ICD-9 tabular you will see verbiage that states; "EXCLUDES conditions due to: intervertebral disc disorders (722.0-722.9)".  I believe that this means that if your documentation indicates a causal relationship between a 722 code and a 724 code (722 caused 724), then the 724 does not get coded.  In your case, you state 'cervical herniated disc at C4-C5 with stenosis'.  This, I believe, is indicating a causal relationship (herniation causes stenosis).  Consequently, I would not code the stenosis.  Now, if your boss/auditor wants to know why you did not code something that is on the report, good luck explaining why!

Richard Mann, your pain management coder
rkmcoder@yahoo.com


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## dwaldman (Apr 19, 2010)

AHA Coding Clinic states: "Do not code symptoms and signs associated with (due to) spondylosis and allied disorders or intervertebral disc disorder (such as slipped disc or arthritic degeneration of interevertebral disc). They are included in the 721-722 code series....."

You could look at the MRI Report and see if the stenosis is due to the disc impinging the nerve roots or thecal sac. Or if the stenosis is unrelated to disc displacement and due to narrowing of foramen or osteophyte build up. It would seem that this type of stenosis would be unrelated to the disc displacment and would not follow the guideline in the ICD-9 book which states Excludes: conditions due to: 722.0-7229, 721.0-721.9 because the stenosis was not due to the disc displacment.


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## BFAITHFUL (Apr 20, 2010)

I work for ASC so I won't have any of that access....... so Im wondering if the operative report doesn't state "due to" not only for this case scenario but for my future reference... then shouldn't I code it since I won't know if this is due to the disc displacement?

& In this scenario, since I don't know if it's "due to" but also I don't know what kind of stenosis it is, should I just leave it out then?

Thanks


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## Anna Weaver (Apr 20, 2010)

It's all according to what's documented, as the other's have said, all indications lead to not coding one if it's caused by the other. I usually look at locations and all documentation before making that decision. If the herniated disc is L2-L3 and your stenosis is L2 or L3, I would not code the stenosis. If the stenosis is thoracic, cervical, or L5, then I would consider coding it with the herniated disc. Good luck.


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## dwaldman (Apr 20, 2010)

"Excludes notes under categories 723, other disorders of cervical region, and 724, other and unspecified disorders of back Symptoms and signs associated with (due to) spondylosis and allied disorders, 721.0-721.91, or intervertebral disc disorders, 722.0-722.93 are included in the 721-722 code series. If the
physician states the symptoms and signs are not attributed to the conditions noted in the excludes note, then use two codes; one from category 723 or 724 and one for the condition. Spinal stenosis due to degenerative disc disease is classified to the 722 category. Spinal stenosis, congenital or NOS, is classified within the 723-724 categories. (See Coding Clinic, third quarter 1994, page 14 and Coding Clinic, second quarter 1989, page 14.)"

http://www.pepperresources.org/LinkClick.aspx?fileticket=pWMPIU2kaWU=&tabid=75&mid=416

 Spinal Stenosis NOS is coded for the lumbar for example is coded as 724.02 but they say if it is due to degenerative disc disease then only code 722. The doctor did not state  it as being due to degenerative disc or secondary to displaced disc which would leave with Spinal Stenosis NOS. Under 722.0-722.6 it states what is considered included include in these codes such as the types of displacement, lumbago, sciatica, or neuritis/radiculitis. It does not say spinal stenosis. You could take the view point that Spinal Stenosis that is not specified should be coded as 723/724 codes and I don't think if that if you would code 722.10 724.02 that this would be miscoding since you don't have documentation that it was "due to" Since it is not documented that it is "due to"  I feel you would still be making an effort to  follow the icd-9 guidelines if you listed 724.02 also.


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## BFAITHFUL (Apr 20, 2010)

yes.. thank you.  But sometimes I get op reports that will have something like the following


Post Op DX:   Cervical Disc herniation at C3-C4
                   Cervical spinal stenosis  (& sometimes just cervical stenosis)


So there really isn't any history there for me to determine where the stenosis really is..... so then would you suggest just leaving it out, or code it since the stenosis could be at a diff. location?


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## dwaldman (Apr 20, 2010)

You could look at the surgery or procedure you are billing and determine if disc displacement for example would accurately describe why the procedure was performed. But in order to justify the reason CPT(s) were performed, if it is necessary to also code stenosis NOS then I would also use this code. If it seems like it is the same physicians doing the same thing, you could talk to the medical records dept which should have contact with the physician. You could ask them to provide them a memo you could create explaining this conflict with the way they are documenting.


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## BFAITHFUL (Apr 21, 2010)

yes.... it is always the same docs & I have tried speaking with their office and sending memo's but no luck... so now I was just trying to see if maybe I can't just code it separately since I don't really know if related or not.. etc...

but I think I will go with what you said....using stenosis NOS

Thank you!!!


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## BFAITHFUL (Apr 22, 2010)

dwaldman..... what stenosis NOS would I use?   there's only 724.00 under "spinal" unspecified region & 724.09 which is also under "spinal" other.  
they're both uner "spinal" but what about when I'm not sure if it's "foraminal" or "spinal"


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## dwaldman (Apr 22, 2010)

http://www.stenosis-spinal.com/different_types_of_spinal_stenosis

I have Ingenix's Diagnoses Coder's Desk Reference, they say this: "To ensure correct code assignment of a herniated disc, the physician should include in the documentation the presense or absence of myelopathy. Spinal Stenosis that is not documented as being degenerative or congential is classified to categories 723-724; however, it is advisable to ask for clarfication from the physician before assigning a nonspecific code. The physician should document the type of spinal stenosis, such as degenerative or congenital, in the medical record. Degenerative spinal stenosis is classified to category 722. Congenital spinal stenosis is classified to categories 723-724.

They don't mention stenosis being include in the 721 codes for spondylosis but  you can also see when this code being used and the stenosis would be included in these codes.
If he states the spinal region and spinal stenosis like they said above not specified as congential or degenerative you could use 723.0 for cervical, 724.01 thoracic, or 724.02 for lumbar.


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## BFAITHFUL (Apr 23, 2010)

thank you so much for all your help!!!


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## dwaldman (Apr 26, 2010)

Stenosis for lumbar 724.02, cervical 723.0, thoracic 724.01, or unspecified 724.00 might work in your case. In regards to foraminal or central, with this code set they do not differ between these separate anatomical locations.


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