MDS Alert

Know regions of the spine to choose appropriate Dx code.

Spinal stenosis can be considered a result of a person’s age and “normal” wear and tear on her body. If you have a resident facing the pain and discomfort of spinal stenosis and she receives an official diagnosis from her physician, you’ll have to navigate the ICD-10 coding. Even coding experts get tripped up by spinal stenosis coding because a person can receive a diagnosis and treatment or evaluation at any stage of the injury.

Your job as a coding expert is to be ready to anticipate how your provider might diagnose spinal stenosis and to know how to choose an ICD-10 code for the condition. Read on for expert advice on all stages of spinal stenosis coding that will keep your next case on the right coding track.

Physicians Confirm Diagnoses in Multiple Ways

Providers can diagnose spinal stenosis in several clinical scenarios, confirms Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare information Services in Park Ridge, Illinois.

To confirm a diagnosis of spinal stenosis, the provider might also “order diagnostic testing services such as X-rays, MRI [magnetic resonance imaging] scans, or CT [computed tomography] scans to view images of the spine,” says Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, AAPC ICD-10-CM Proficient, AAPC Fellow, senior manager of healthcare consulting at Seim Johnson LLP in Omaha, Nebraska.

Listen for Complaints of Extremity Pain

Residents who receive a diagnosis of spinal stenosis from their physicians often present with similar symptoms; many complain of “numbness and/or tingling in the extremities, and pain in the spine or extremities,” Anderanin explains.

Swanson agrees, adding “signs/symptoms of spinal stenosis may include neck pain, weakness, or numbness in shoulders, arms, legs, hand clumsiness, gait imbalance disturbance, burning, or tingling involving extremity such as arms or legs.”

Look to These ICD-10 Codes for Stenosis

Once the resident’s physician confirms spinal stenosis, you’ll need to deftly handle the ICD-10 options to choose the optimal code. Here are the codes you’ll choose from for all your standard spinal stenosis residents, depending on encounter specifics:

• M48.00 —  Spinal stenosis, site unspecified
• M48.01 — … occipito-atlanto-axial region
• M48.02 — … cervical region
• M48.03 — … cervicothoracic region
• M48.04 — … thoracic region
• M48.05 — … thoracolumbar region
• M48.06_ — … lumbar region
• M48.07 — … lumbosacral region
• M47.08 — … sacral and sacrococcygeal region.

Important: For residents with lumbar stenosis (M48.06_), you’ll need to make a sixth character decision, depending on whether neurogenic claudication accompanied the stenosis.