Once diagnosis is established, treatment options are numerous. Patients reporting for diagnosis or treatment of spinal stenosis can throw you for a loop if you aren’t ready. There are several ways to diagnose and treat the condition, which can lead to some confusion when it’s time to code. Help’s here: To get the facts straight on stenosis, we talked to Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois; and 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. Here’s what they had to say. Q: How does a provider diagnose spinal stenosis? Anderanin “A provider normally can anticipate stenosis in an evaluation and management [E/M] visit, but it would normally be confirmed in an MRI [magnetic resonance imaging] or CT [computed tomography].” Swanson “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 scans, CT scans to view images of the spine.” Q: What are some of the symptoms of spinal stenosis? Anderanin “Numbness and/or tingling in the extremities. Pain in the spine or extremities.” Swanson “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.” Q: How does a provider treat spinal stenosis? Anderanin Some of the surgical treatments include: Note: This is not a complete list of treatments for spinal stenosis, and the above treatments will probably be performed by someone other than your provider. Swanson “Treatment for diagnosis of spinal stenosis can include such modalities as medication, physical therapy, steroid injections and surgery.” Codes that could be used include: Note: This is not a complete list of treatments for spinal stenosis, and the above treatments could be performed by someone other than your provider — though your provider could also perform these services. Q: What are some conservative (nonsurgical) treatments that a provider might attempt for spinal stenosis patients? Anderanin “Steroids, therapy, exercise, anti-inflammatories.” Swanson “Medications, physical therapy, acupuncture, massage and chiropractic treatments are conservative options patients may try.”