Neurology & Pain Management Coding Alert

Question: My physician performed a physical exam on a patient that led to a conclusion of diminished deep tendon reflex. My physician ordered an EMG, but the EMG results were normal. Where can I find a diagnosis code for diminished deep tendon reflexes?

Alabama Subscriber

Answer: Your best bet may be 796.1 (Abnormal reflex), a nonspecific abnormal finding, based on ICD-9 chapter 16 guidelines. These state that the conditions and signs or symptoms included in categories 780-796 consist of cases for which no more specific diagnosis can be made even after all facts bearing on the case have been investigated; signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; or cases in which a more precise diagnosis was not available for any other reason.

Alternative: Investigate using 781.99 (Other symptoms involving nervous and musculoskeletal systems). Check the payers coverage policy for electrodiagnostic testing to see if this sign/symptom meets its medical necessity requirements. You may also need to check with your physician to see if the patient had any other complaints or physical findings that were the reason for the EMG testing.