Anesthesia Coding Alert

Pay special attention to accompanying conditions.

Before you assign ICD-10-CM codes to any case, always double check your provider’s medical record to ensure you caught all of the important details about the diagnosis. One example when reporting a pain management specialist’s services is sciatica: Know which side of the patient’s body is affected by the condition. As innocuous as that detail might seem, failing to determine those types of details could put you at risk for submitting incorrect claims – and receiving inaccurate reimbursement.

Back to basics: “You should always report the most specific diagnostic code available,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute at the JFK Medical Center in Edison, New Jersey.

In the following examples, you will see that a condition as simple as sciatica (i.e., leg pain) is reported based on the side of symptoms, the presence or absence of back pain, and whether the problem is from a lesion of the sciatic nerve itself.

Read on to learn more best practices for picking the best sciatica ICD-10 code for each patient.

Get Familiar With Sciatica Symptoms

If your provider treats patients with sciatica, you should know what symptom details to look for in the medical record.

For example, a patient presents with compression of a lumbar nerve root. This patient complains of leg pain. In the medical documentation, your provider documents tingling and numbness. He adds that the patient’s symptoms started in the patient’s lower back and then radiated through her buttocks and down the sciatic nerve in her leg.

Pinpoint Sciatica’s Exact Location

Since ICD-10-CM offers different codes for sciatica depending upon the body’s affected side, you must check your provider’s medical documentation and confirm where the patient’s sciatica was located. You have these codes to look to for a sciatica diagnosis:

• M54.30 (Sciatica, unspecified side)
• M54.31 (Sciatica, right side)
• M54.32 (Sciatica, left side)

Coding example: The physician documents that the patient has sciatica on her left side. You would report M54.32 for this condition.

Code Differently for Sciatica With Lumbago

If your provider documents lumbago (low back pain) along with the patient’s sciatica, that leads you to a different set of codes from which to choose. When looking at these codes, you must know the side of the patient’s body affected to pick the appropriate code. You can look to the following codes for lumbago with sciatica:

• For lumbago with sciatica on the right side, you should report M54.41 (Lumbago with sciatica, right side).
• For lumbago with sciatica on the left side, you should report M54.42 (Lumbago with sciatica, left side).
• When your physician does not document which side the symptoms were present, you should report code M54.40 (Lumbago with sciatica, unspecified side).

Keep the Documentation in Order

Educate your providers on the importance of documenting the patient’s condition as thoroughly as possible so you can select the most appropriate diagnosis. For example, this is an extremely important concept for sciatica and other diagnoses that depend upon laterality. If you know details such as the affected side and if other symptoms also are present (such as lumbago), then you can code more accurately.

Remember: To help your provider to remember to document these details, you can include a note of “laterality” beside the sciatica diagnosis on the superbill.

Check ‘Excludes’ Notes for Sciatica

When using the ICD-10-CM manual, you should always check for notes to make sure you submit your claims correctly.

For example, the sciatica category, M54.3- (Sciatica), has an Excludes1 note that tells you not to report these sciatica codes with lesion of sciatic nerve (G57.0), sciatica due to intervertebral disc disorder (M51.1-), or sciatica with lumbago (M54.4-).