Neurosurgery Coding Alert

Don’t mix up radiculopathy and myelopathy.

When it comes to reporting cervical disc disorders, you will encounter numerous diagnosis codes and treatment options. For example, make sure you read the documentation carefully to see if the patient has myelopathy or radiculopathy.

Hone your cervical disc disorder knowledge by answering the following questions.

Turn to These Codes for Myelopathy

Question 1:  Which ICD-10 codes should you look to if the surgeon documents that the patient has a cervical disorder with myelopathy?

Answer 1: If the patient has a cervical disorder with myelopathy, you should turn to the M50.0- (Cervical disc disorder with myelopathy) code set.

Myelopathy defined: “Myelopathy are the symptoms caused by something compressing a portion of the spinal cord,” explains Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois. Keywords/phrases to look for in the notes for myelopathy include impaired fine hand function, gait impairment, stiffness, numbness, and/or weakness.

Caution: You should learn to spot the signs of myelopathy, because your provider is unlikely to spell it out. “I do not see most providers documenting the word ‘myelopathy,’ but they will document the symptoms,” Anderanin says.

When selecting a code from the M50.0- code set, you’ll need to include a fifth character, and in some cases a fifth and sixth character, for greater specificity. For example, if the notes indicate that the patient suffers from a cervical disc disorder at C4-C5 with myelopathy, you’ll choose M50.021 (Cervical disc disorder at C4-C5 level with myelopathy) as the patient’s diagnosis.

Note: The codes for mid-cervical disc disorders mandate a sixth character to indicate spinal level, while the codes for high or unspecified cervical regions only require five characters.

Distinguish Between Radiculopathy and Myelopathy for Accuracy

Question 2: If the patient suffers from a cervical disc disorder with radiculopathy, which codes should you turn to?

Answer 2: The code set M50.1- (Cervical disc disorder with radiculopathy) addresses radiculopathy, which “pinches the spinal nerve roots and could also be caused from bone or soft tissue abnormalities,” says Denise Paige, CPC, COSC, of PIH Health in Whittier, California.

The distinction: While some of the symptoms of radiculopathy and myelopathy are similar (both can have numbness, weakness, hand or gait dysfunction), myelopathy is typically painless while radiculopathy is typically painful, explains Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

So, if you’re trying to decide between myelopathy and radiculopathy, you might be able to glean enough info from the encounter notes to indicate radiculopathy, which is typically unilateral and associated with pain. If you cannot, however, you can always contact the provider.

Code selection from the M50.1- set includes fifth — and in some cases fifth and sixth — character selection. So, for example, if notes indicate that the patient suffers from a cervical disc disorder at C5-C6 with radiculopathy, you’ll choose M50.122 (Cervical disc disorder at C5-C6 level with radiculopathy) as the diagnosis.

Note: As with the codes for myelopathy, codes for mid-cervical disc disorders for radiculopathy require a sixth character to indicate spinal level, while the codes for high or unspecified cervical regions only require five characters.

Report These Codes for Diagnostic Procedures

Question 3: Can you explain some of the typical diagnostic tests a surgeon may perform when he confirms or denies a suspected cervical disc disorder?

Answer 3: Your provider might suspect a cervical disc disorder, which could result in a diagnostic procedure. When the spine specialist performs a diagnostic test to confirm or deny the disorder, it’s normally from one of these code sets:

• X-ray: 72040 (Radiologic examination, spine, cervical; 2 or 3 views) through 72052 (… 6 or more views).
• Magnetic resonance imaging (MRI): 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material), 72142 (… with contrast material(s)), or 72156 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical).