Anesthesia Coding Alert

Plus: Prepare now for expanded diagnosis choices under ICD-10.

Your physician's notes document "radiculopathy," but that doesn't send you to a clear-cut diagnosis code. Dig deeper for the cause of the patient's problem and the affected region to make the best choice.

Identify the Signs and Causes

Radiculopathy occurs when one or more spinal nerve roots become inflamed, compressed, or suffer a compromised blood supply. The nerve root problem can lead to pain, weakness, or numbness in the region(s) affected by the individual spinal nerve(s).

ICD-9 Includes two primary choices for radiculopathy diagnoses: ICD-9 723.4 (Brachial neuritis or radiculitis NOS) or ICD-9 724.4 (Thoracic or lumbosacral neuritis or radiculitis, unspecified).

Caution: Diagnosis ICD-9 724.2 (Lumbago) refers to lumbago or low back pain. Radiculopathy in the lumbosacral region of the spine can present as low back pain, so it's important to determine whether the patient has low back pain or radiculopathy.

Common causes of low back pain include disc degeneration, spondylosis, sprain, muscle trigger point, fibromyalgia, compression fracture, or injury, according to Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. These causes differ from those for radiculopathy, which is why knowing the underlying circumstances can help your physician diagnose -- and you code -- correctly.

Watch for the Affected Region

When reporting radiculopathy, focus on the spinal region involved. The anatomical location of the patient's symptoms (cervical, thoracic, lumbar, sacral, or coccygeal) is your best guide.

Reminder: The affected regions may overlap, but the nerve roots are discrete. Your physician might document nerve roots that cross from one anatomic region to another, such as L5-S1. You'll report the lumbosacral regional involvement.

Prepare for More Detailed Choices With ICD-10

When ICD-10 goes into effect, you'll find eight possible codes for radiculopathy. Each involves a specific spinal region:

• M54.11 -- Radiculopathy, occipital-atlanto-axial region
• M54.12 -- Radiculopathy, cervical region
• M54.13 -- Radiculopathy, cervicothoracic region
• M54.14 -- Radiculopathy, thoracic region
• M54.15 -- Radiculopathy, thoracolumbar region
• M54.16 -- Radiculopathy, lumbar region
• M54.17 -- Radiculopathy, lumbosacral region
• M54.18 -- Radiculopathy, sacral and sacrococcygeal region.

Note: Having more specific diagnosis choices under ICD-10 means providers will need to be more detailed in their documentation so you can code more accurately. Although ICD-10 won't be implemented until October 2014, now is the perfect time to start helping your providers prepare for how their documentation will change.