Neurology & Pain Management Coding Alert

Did your provider go beyond E/M for confirmation? You might be able to code a procedure.

When a patient reports to the physician with symptoms of spinal stenosis, things can get tough fast for the unprepared coder.

Coding conundrum: A patient with spinal stenosis could come in at any stage of the injury — pre-diagnosis or post-diagnosis — for treatment or evaluation.

As a coder, you must be ready to know how your provider might diagnose spinal stenosis and how to choose an ICD-10 code for the condition. Check out this expert advice on all stages of spinal stenosis coding.

Physicians Use E/M, MRI to Confirm

Providers can diagnose spinal stenosis in a number of clinical scenarios, confirms Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. In fact, the condition can often be identified in an evaluation and management (E/M) office visit — which you’d code with 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making … ) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …), depending on encounter specifics.

To confirm a diagnosis of spinal stenosis, the provider might also “order diagnostic testing services such as X-rays, MRI [magnetic resonance imaging] scans, or CT [computed tomography] scans to view images of the spine,” says 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.

Check for Extremity Pain for Possible Stenosis Px

Patients that walk out of the practice with a diagnosis of spinal stenosis often walk in with similar symptoms; many complain of “numbness and/or tingling in the extremities, and pain in the spine or extremities,” explains Anderanin.

Swanson agrees, adding “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,”

Use These ICD-10 Codes Upon Stenosis Confirmation

Once your physician confirms spinal stenosis, you’ll need to deftly handle the ICD-10 options to choose the optimal code. Here’s the codes you’ll choose from for all your standard spinal stenosis patients, depending on encounter specifics:

• M48.00 — Spinal stenosis, site unspecified
• M48.01 — … occipito-atlanto-axial region
• M48.02 — … cervical region
• M48.03 — … cervicothoracic region
• M48.04 — … thoracic region
• M48.05 — … thoracolumbar region
• M48.06_ — … lumbar region
• M48.07 — … lumbosacral region
• M47.08 — … sacral and sacrococcygeal region.

Remember: For patients with lumbar stenosis (M48.06_), you’ll need to make a sixth character decision, depending on whether or not neurogenic claudication accompanied the stenosis.