Neurology & Pain Management Coding Alert

Pain in spine or extremities? It could be spinal stenosis.

Patients who have symptoms of spinal stenosis, but no diagnosis, are the type of patients you might see at your practice.

Why? Your provider will often be the one to diagnose the condition, which can take several steps, attempts, patient visits — and CPT® codes.

That’s where the coder comes in. Failure to grasp coding concepts surrounding spinal stenosis can result in problems with claims for your provider’s services. Read on for more information on how the provider diagnoses spinal stenosis, and how to code for the services.

Note These Symptoms

“Signs and 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,” explains 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.

If a patient reports exhibiting these symptoms, “practitioners most commonly diagnose spinal stenosis by taking a medical history, performing an examination and observing patient movements. They may 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 Swanson.

Count on These Codes for Dx Procedures

The first step in treating spinal stenosis is identifying it. Your provider will diagnose the condition with a combination of evaluation and management (E/M) services and imaging.

“A provider normally can anticipate stenosis in a visit, but it would normally be confirmed in an MRI or CT,” explains Lynn M. Anderanin, CPC, CPB,CPMA,CPPM, CPC-I,COSC, senior coding educator at Healthcare Information Services, LLC in Park Ridge, Illinois.

Here’s a sampling of some of the CPT® codes associated with E/M codes, X-rays, CT scans, and MRI scans your provider might perform to diagnose spinal stenosis.

E/M: For the most part, your provider will initially see spinal stenosis patients in the office, which means you’ll report a code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set, depending on encounter specifics.

X-rays: Use codes from 72020 (Radiologic examination, spine, single view, specify level) through 72120 (Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views) for X-rays that check for spinal stenosis. The codes include, but are not limited to, the following:

• 72040 (Radiologic examination, spine, cervical; 2 or 3 views)
• 72081 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view)

CT scans: Use codes 72125 (Computed tomography, cervical spine; without contrast material) through 72133 (Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections) for CT scans that check for spinal stenosis. The codes include, but are not limited to, the following:

• 72128 (Computed tomography, thoracic spine; without contrast material)
• 72131 (Computed tomography, lumbar spine; without contrast material)

MRI scans: Use codes 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material) through 72158 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar) for MRI scans that check for spinal stenosis. The codes include, but are not limited to, the following:

• 72146 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material)
• 72148 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material))
• 72156 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical)

Also: Though the diagnosis might be spinal stenosis in the end, the provider might need to perform X-rays, CT scans, or MRI scans on extremities in order to diagnose spinal stenosis — particularly if the patient complains of pain/tingling in the extremities.

When this occurs, you should select a code from 73000 (Radiologic examination; clavicle, complete) through 73723 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences), depending on encounter specifics.

Find Stenosis Diagnoses in M48.0-

If your provider reaches a diagnosis of spinal stenosis, you’re going to want to make sure that you choose the correct ICD-10 code for the condition. The codes you’ll choose from to diagnose spinal stenosis are:

• M48.01 (Spinal stenosis, occipito-atlanto-axial region)
• M48.02 (Spinal stenosis, cervical region)
• M48.03 (Spinal stenosis, cervicothoracic region)
• M48.04 (Spinal stenosis, thoracic region)
• M48.05 (Spinal stenosis, thoracolumbar region)
• M48.061 (Spinal stenosis, lumbar region without neurogenic claudication)
• M48.062 (Spinal stenosis, lumbar region with neurogenic claudication)
• M48.07 (Spinal stenosis, lumbosacral region)
• M48.08 (Spinal stenosis, sacral and sacrococcygeal region)

Example: An established patient reports to the office complaining of pain in the lower spine. After an E/M service that includes moderate medical decision making (MDM), the provider performs a lumbar MRI. The MRI confirms lumbar spinal stenosis without neurogenic claudication.

For this encounter, you’d report:

• 72148 for the MRI.
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M service.
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99214 to show that the MRI and E/M were significant, separately identifiable services.
• M48.061 appended to 72148 and 99214 to represent the patient’s stenosis.