Neurology & Pain Management Coding Alert

Make sure laterality, anatomy are marked in codes if necessary.

A big part of diagnosis coding has absolutely nothing to do with selecting ICD-10 codes.

Huh? If the provider doesn’t include documentation in the medical record on all potential aspects of a condition, the coder cannot choose the most accurate ICD-10 code for the patient. This could lead to miscoding the patient’s condition, or a time-consuming query to get the information just right.

Do this: Check out this primer on coding common neurological disorders, and make sure you and your providers are on the same page with each and every ICD-10 code choice.

Document, Document, Document

If it’s not documented, it didn’t happen. These words, or variations of them, have been heard by every coder in the land.

According to guidance from Cape Fear Valley Health in North Carolina, there are certain documentation requirements that need to be met for certain neurological diagnoses to be accepted. Failure to meet these requirements could result in your patient being misdiagnosed or a refusal of services from the payer.

Note These Specifics for Alzheimer’s Patients

When a patient has Alzheimer’s disease, the provider should document early or late onset. If the patient has dementia in addition to Alzheimer’s, documentation should also include with/without behavioral disturbance. “For example, combative or aggressive behavior,” Cape Fear Valley Health reports.

When a patient suffers from attention deficit hyperactivity disorder (ADHD), documentation for ADHD should include the ADHD type, such as predominantly inattentive, predominantly hyperactive, or combined type.

Cognitive Signs Could Signal Something Else

When a patient suffers from cognitive signs and symptoms, it’s important to document just how these symptoms could be indicative or related to another condition.

The provider should identify when signs and symptoms relate to a known mental disorder. They should also list any associated current injuries or late effects of past events. Finally, the cognitive signs and symptoms documentation should clarify the type of mental disturbance: altered mental status, age-related cognitive decline, confusion, dementia, etc.

Another diagnosis that requires extra documentation is diabetic neuropathy. For diabetic neuropathy patients, Cape Fear Valley Health recommends that the provider document specifically the type of neuropathy the patient has, if possible. These types include:

• Diabetic mononeuropathy
• Diabetic autonomic neuropathy
• Diabetic amyotrophy
• Other neurological complication

For diabetic neuropathy patients, the documentation should also include whether the patient has maintained appropriate blood glucose levels. If they haven’t, the provider should document the insulin control status as either inadequately controlled, out of control, or poorly controlled.

Tie Headache, Migraine to These Documentation Points

When a patient reports with a headache, you’ll want to get the provider to document the headache type first. Headache types include:

• Cluster
• Vascular
• Tension-type
• Posttraumatic
• Drug-induced
• The provider should also document whether the headache is tractable or intractable, and the timing of the headache. Headache timing documentation could include terms like:
• Episodic
• Chronic
• Episodic paroxysmal hemicrania
• Chronic paroxysmal hemicrania
• Short-lasting unilateral

While migraine is a close cousin to headache, it is entirely its own condition — and it has its own documentation requirements. You’ll first need the provider to identify migraine type. Migraine types include:

• Migraine with/without aura
• Hemiplegic migraine
• Persistent migraine aura with/without cerebral infarction (CI)
• Chronic migraine

If the migraine is due to drugs, the provider should document it, along with whether the migraine was tractable/not intractable and with/without status migrainosus. If the migraine is associated with seizures or CI, the provider should note that as well.

Location Keys Myalgia Documentation

When patients suffer from myalgia, coders will need the documentation to reflect the location of the condition: the anatomical area and the laterality. Areas a patient might suffer myalgia include:

• Shoulder
• Upper arm
• Forearm
• Hand
• Fingers
• Thigh
• Ankle

But the documentation requirements don’t stop there. The provider should also include “when paralysis or burns accompany the calcification and ossification of muscles,” Cape Fear Valley Health reports. Further, if there are any ruptures accompanying the myalgia, they should be listed. Myalgia rupture types include:

• Nontraumatic ischemic
• Infarction
• Wasting
• Contracture of a muscle.