Neurology & Pain Management Coding Alert

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:

• 22610 (Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed))
• 22614 (… each additional vertebral segment (List separately in addition to code for primary procedure))
• 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar) and 22633 (… lumbar)
• 22862 (Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar) and 22864 (Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical).

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:

• 62320 (Injection(s) of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance)) through 62327 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT))
• 97010 (Application of a modality to 1 or more areas; hot or cold packs) through 97028 (… ultraviolet)
• 97161 (Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.) through 97164 (Re-evaluation of physical therapy established plan of care, requiring these components: an examination including a review of history and use of standardized tests and measures is required; and revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.).

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.”