Anesthesia Coding Alert

Question: The provider consulted with a patient two weeks after a cervical laminectomy for spinal stenosis. The patient complained of severe pain at the operative area. Our provider is concerned that the patient may be experiencing post-laminectomy syndrome. What ICD-10 codes would apply?

Florida Subscriber

Answer: You have three diagnoses to consider in this situation. First, don’t assume that the primary diagnosis should be M48.02 (Spinal stenosis, cervical region) since that’s the basis behind the procedure. Instead, check out these ICD-10 guidelines on coding complications from surgery.

According to Section II, Part G in the ICD-10-CM, “When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 104 of 117 specificity in describing the complication, an additional code for the specific complication should be assigned.”

Because of this, do not submit M48.02 as the principal diagnosis – it’s not applicable since the patient has technically already been treated for the stenosis. Instead, you need to determine the correct surgical complication code for postoperative cervical spine pain. Since surgical complication codes tend to lack specificity in respect to anatomical sites, the most accurate code available is G89.18 (Other acute postprocedural pain).

Caution:  “The provider’s speculation that the patient is experiencing post-laminectomy syndrome is not enough to warrant a diagnosis code,” explains Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “However, if the provider definitively concluded that the patient was suffering from post-laminectomy syndrome, you would exclusively apply code M96.1 [Postlaminectomy syndrome, not elsewhere classified] without the need for G89.18,” she adds.