Neurology & Pain Management Coding Alert

Question: A private payer has denied our claim for a pain management office visit for “missing/incomplete/ invalid principal diagnosis.” One of our coders says we cannot report M54.16 and M51.26 on the same claim, but I have never seen anything stating this. Who is right and how should we have coded the service?

Washington Subscriber

Answer: Assuming the diagnosis codes you mention are correct for the procedure, your coding colleague is correct. When a patient has a herniated or displaced disc with radiculopathy, the correct ICD-10 diagnosis code is M51.16 (Intervertebral disc disorders with radiculopathy, lumbar region). Diagnosis M51.16 is a combination code that describes both problems the patient is experiencing (displaced disc and radiculopathy). Because of this, there is no need to also report diagnosis M51.26 (Other intervertebral disc displacement, lumbar region).

Reminder: Insurers state that you should report the code that best describes the problem; when a combination code applies (from either a diagnosis or procedure perspective), they expect you to submit it instead of multiple codes. If you report multiple diagnoses when a combination code describes all the problems, the insurer sees your claim as miscoded.